Jan 2023 – Jan 2024 · 1 yr

• Responsible for overseeing clinical and quality performance across twelve independent primary care providers in a full-risk value-based program. Led the implementation of regional strategies to enhance clinical outcomes and quality metrics, including HEDIS and CAHPS programs. Streamlined operations and expanded reporting capabilities to optimize provider performance and reduce financial risk. Actively participated in joint operating committee meetings at national, regional, and local levels to align health plan objectives with market outcomes.

Jan 2022 – Jan 2023 · 1 yr

• Led clinical strategy execution across eastern region markets, managing twelve independent primary care providers within a full-risk value-based program. Successfully implemented clinical initiatives targeting Medicare Advantage, Medicare FFS, and D-SNP patient populations, resulting in reduced medical expenses and improved outcomes. Developed and implemented innovative palliative and renal care programs, achieving significant cost savings and enhancing patient care quality. Provided clinical guidance and supported new market implementations to drive performance and model adoption.

Jan 2019 – Jan 2022 · 3 yrs

• Provided strategic leadership for a primary care group participating in a Medicare global risk model. Developed and implemented a physician-led population health care model aimed at improving quality, reducing costs, and enhancing patient and provider satisfaction. Achieved substantial savings through evidence-based clinical models and innovative care management strategies for chronic conditions like CHF and COPD. Led the implementation of a practice-based palliative care program, exceeding savings targets and improving patient outcomes.

Jan 2016 – Jan 2019 · 3 yrs

• Formulated market and business strategies for twelve national and regional accounts, specializing in managed care. Negotiated and implemented value-based agreements, driving year-over-year increases in per patient day revenues and capitation payments. Established strategic alliances and partnerships, including with United Health Care I-SNP, resulting in significant growth in I-SNP facilities. Improved operational metrics and patient outcomes through collaborative efforts with naviHealth, focusing on reducing LOS and improving discharge processes.

Jan 2013 – Jan 2016 · 3 yrs

• Developed and implemented regional case management programs across twenty facilities, optimizing skilled nursing utilization and transitions of care. Led a team of twelve case managers, implementing processes that increased revenue and improved Pay for Performance (P4P) compliance. Developed strategic initiatives to enhance patient care quality and operational efficiency, resulting in substantial cost savings and improved financial outcomes for the division.

Jan 2013 – Jan 2013 · 0 mo

• Monitored and trended utilization patterns for Medicare and Medicaid products, identifying opportunities for cost containment and quality improvement. Led initiatives to optimize utilization through data-driven analysis and collaboration with healthcare providers. Implemented strategies to reduce unnecessary utilization and improve patient outcomes, ensuring compliance with regulatory requirements and accreditation standards.

Jan 2009 – Jan 2013 · 4 yrs

• Instructed and supervised student nurses in clinical settings, focusing on skilled nursing and acute hospital environments. Collaborated with department heads to develop and assess learning outcomes, contributing to program reviews and curriculum revisions. Applied extensive clinical expertise to facilitate student learning and prepare future healthcare professionals for real-world challenges.

Jan 2007 – Jan 2013 · 6 yrs

• Managed a team of 35 RNs responsible for post-hospital care utilization reviews across multiple healthcare settings. Implemented strategic initiatives and rapid improvement events, achieving significant operational efficiencies and cost savings. Developed and mentored staff, fostering a culture of continuous improvement and excellence in care management practices.

Jan 2003 – Jan 2007 · 4 yrs

• Responsible for the implementation of effective utilization management strategies, including: review of appropriateness of healthcare services, application of criteria to assure appropriate resource utilization, identification of opportunities for Condition Management, Case Management initiatives, education of network providers, and identification and resolution of quality issues. Analyze qualitative and quantitative data to improve provider performance and member satisfaction. Participant in a successful work at home pilot. Knowledgeable of Quality Improvement Organization process for fast track appeals. Experience utilizing InterQual criteria for utilization reviews.