Senior Registered Nurse Clinician and Leader Quality Imp and Reg Affai

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October 24, 2025

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PROFESSIONAL SUMMARY

Results-driven Senior Nurse Leader and retired Navy Nurse Corps Officer with almost 30 years of experience driving excellence in hospital and health plan accreditation. Proven record of accomplishments collaborating with diverse stakeholders, from frontline staff to senior administration, to achieve strategic goals. Exceptional problem-solver with a talent for navigating high-pressure situations. I will use my expertise in regulatory affairs, compliance monitoring, quality improvement, and program management to drive transformative outcomes. With a solid foundation in patient safety, care delivery, education, and resource management, I am poised to propel your organization's multi-year strategic goals forward by harnessing my abilities to elevate team's performance and achieve lasting impact.

SKILLS AND ABILITIES

Hospital

Strategic planning, Performance Improvement (HROs), Joint Commission Accreditation, PCMH certification, Regulatory compliance, monitoring and auditing, policy writing, evaluating quality and safety of patient care

Health Plan

Strategic planning, value-based care provider incentive program manager, case management; utilization review, provider networking and trainings, NCQA Medicare/Medicaid accreditations, HEDIS – Audits/Primary Source Verification/Medical Record Abstraction and Review Validation, performance improvement, population health, Illinois Department of Public Health audits, member program design and implementation, evaluation of program success and effectiveness and, oversight and investigation of member grievances

OTHER Skills (Supported by work experience)

Leader/instructor/trainer/coach/mentor

Excellent written and verbal communication

Excellent organizational and time management skills

Flexible. Can multi-task even with change in priorities

Self-motivated. Can work independently and/or lead teams

Meeting facilitation and preparation

Quantitative/qualitative data/process analyses

Project management and execution ability

Proficient in Microsoft Office and Sharepoint

EXPERIENCE

Cook County Health (Chicago, Illinois) 07/2022 – 11/2024

Associate Director, Quality, Regulatory Affairs and Accreditation

Led a cross-functional team in implementing a new policy management system, completing the project on time and within budget

Collaborated with executive leadership to promote a coordinated approach to compliance and policy development

Developed and disseminated a comprehensive training guide to enhance staff knowledge and response to accreditation and regulatory questions

Conducted daily rounds to assess departmental compliance with regulatory requirements

Identified and addressed deficiencies, assisting as needed with corrective action plans that ensured regulatory compliance

Administered the online policy management program, ensuring policies were current and compliant with regulatory changes

Maintained database of audit findings and corrective actions, coaching teams through compliance

Collaborated with stakeholders to develop and maintain policies and procedures, promoting timeliness and consistency across hospitals and clinics

Met weekly with department leaders to monitor progress and completion of corrective action plans

Served as a resource for staff on policy and procedure development

Provided training and support to ensure accuracy and consistency of policies and procedures organization-wide

CountyCare Health Plan Cook County Health (Chicago, Illinois) 08/2014 – 7/2022

Quality Manager

Led team that increased HEDIS performance, coordinating annual health fairs, resulting in significant improvements, for example: BCS increased 20%, CDC eye exams increased 30% year over year

Promoted value-based care by developing a provider incentive program focused on improving member health outcomes

Procured a population health program targeting high-risk, high-volume members to increase member engagement and enrollment in self care management activities

Managed HEDIS and quality improvement programs and audits, ensuring 95-100% compliance standards year over year

Improved member/provider satisfaction through strategic initiatives and leadership of Member Satisfaction Committee

Developed and managed quality work plan, prioritizing initiatives and achieving 75% goal completion annually

Analyzed data for quality improvement, identifying areas for improvement, implementing strategies for success, sharing results with care management teams for additional actions aimed at decreasing costs from high-risk and high-cost member

Created monthly HEDIS reports to share with providers promoting value-based care initiatives

Authored plan policies ensuring policies were accurate and and consistent with evidence- based practices

Oversaw quality of care investigations and grievances, trending results and implementing improvements

Collaborated with Network team to improve member empanelment accuracy and care management effectiveness by aligning accurate HEDIS reports with the right provider or medical home

Chamberlain College of Nursing (Jacksonville, Florida) 01/2012 – 03/2014

Nursing Instructor

Developed RN student curriculum and facilitated classroom instruction for two nursing specialties: Obstetrics and Medical/Surgical Nursing to an average of 20 students

Provided hands own clinical training at local patient care facilities in Obstetrics and Gynecology, Critical Care, Medical-Surgical, and rehab Stroke and Post-Intervention Neuro by precepting and offering more training opportunities through laboratory simulated activities.

Prepared and submitted student grades and monthly evaluations

Evaluated the effectiveness of the nursing program by monitoring student survey responses for areas of the curriculum needing improvement

Southeastern College (Jacksonville, Florida) 06/2012 – 12/2012

Nursing Instructor

Facilitated learning in the classroom, laboratory and in the clinical setting in various long-term care, rehabilitation, and drug rehab facilities for LPN students

Devoted personal time to take part in the professional development and mentoring of students resulting in an above 90% pass rate for the PNCLEX when average class pass rate on first try was around 80%

Developed course curricula and lesson plans introducing-innovative strategies to approach adult learning

Assisted in the interview process to recruit the best qualified students

Served on committees offering valuable subject matter input on student’s nursing educational needs

Prepared and submitted student grades and conducted monthly evaluations

Naval Hospital Beaufort (Beaufort, South Carolina) 08/2008 – 08/2010

Clinic Manager – Oral Surgery Clinic (08/2009 – 08/2010

Spearheaded day-to-day clinic operations, supervising a team of 6 staff members and driving efficiency

Delivered comprehensive preoperative education, moderate sedation, and recovery services for outpatients undergoing oral procedures

Developed and implemented practice and performance standards for support staff, resulting in: 25% increase in clinical availability of surgeons

Improved patient services and access

Contributed to patient safety as a member of the Emergency Response Code Team, conducting monthly drills and responding to actual codes

Served as financial auditor for the Third-Party Collection Program, overseeing $250,000 in average monthly balances and ensuring accurate reporting

Used expertise as a certified PACU nurse on the American Society of Perianesthesia Nurses (ASPAN) Standards Committee, providing evidence-based guidance and education

Advanced performance improvement initiatives through committee work, developing and implementing projects to measure and improve patient care, such as reducing no-show rates

Promoted a culture of respect and compliance as an Equal Opportunity Specialist, educating staff on Navy rights and responsibilities, and addressing sexual harassment concerns

Naval Hospital Beaufort (Beaufort, South Carolina) 08/2008 – 08/2010

Department Head – Ambulatory Procedures Department 08/2008 – 08/2009

Spearheaded department operations, supervising a team of 10 staff members (three surgeons and 6 support staff and driving efficiency

Improved patient wait times by 19 minutes (66% reduction) by establishing an additional patient education room to accommodate walk-in appointments

Identified and corrected a 40% deficit in Anesthesia's workload reporting, resulting in a $650,000 increase in the directorate's FY2010 budget

Acquired a medication dispensing unit for the Ambulatory Surgery Unit (ASU), streamlining medication delivery and enabling patients to receive timely treatment for acute symptoms

Developed a comprehensive orientation program for PACU staff, ensuring new nurses and cross-training staff had the necessary knowledge and skills to provide high-quality patient care in the acute-postoperative environment

Navy Hospital Jacksonville (Jacksonville, Florida) 08/2005 – 08/2008

Nurse Manager – Post Anesthesia Care Unit, (06/2006 – 08/2008)

Led a performance improvement initiative to reduce PACU length of stay (LOS) variances, utilizing an evidence-based formula to estimate LOS based on procedure type, anesthetic used, and other factors

Achieved a 60% reduction in pain-related LOS variances by implementing best practices and monitoring and trending results

Contributed to the American Society of Perianesthesia Nurses (ASPAN) Clinical Practice Committee, using expertise in Standards of Perianesthesia Nursing Practice and clinical resources

to educate other PACU nurses perianethesia care and management

Successfully managed scheduling to optimize resource utilization, enabling the return of over 550 active-duty personnel to full duty despite staffing challenges

Implemented cost-saving strategies, reducing annual costs by $300,000 through avoided network referrals

Maintained certification in perianesthesia nursing (CPAN)

Navy Hospital Jacksonville (Jacksonville, Florida) 8/2005 – 08/2008

Military Deployment (Guantanamo Bay, Cuba)

Critical Nurse – Detainee Advanced Care Unit 02/2007 – 07/2007

Delivered urgent and emergency care to over 600 detainees in a maximum-security military prison environment, demonstrating expertise in high-pressure situations

Spearheaded the Specialty Care Unit, overseeing multi-bed critical care services for critically ill or injured detainees

Ensured 100% compliance with best clinical practices as the program manager for the nurse Tuberculosis Screening program

Trained over 700 security personnel on infection control measures, promoting a safer environment and mitigating the risk of life-threatening diseases

Recognized with the Joint Services Commendation for exceptional care and dedication to providing high-quality services to detainees

Navy Hospital Jacksonville (Jacksonville, Florida) 8/2005 – 08/2008

Charge Nurse – Labor and Delivery 08/2005 – 06/2006