PROJECTS

Performed process improvement assessment to identify areas of risk, gaps and the root cause of deficiencies.  Assessment included process mapping, value-add/non-value-add analysis, time studies for each function, review of member letters, staff interviews, assessment of regulatory knowledge and evaluation of policies and procedures.  Turn around project with technology solution implementation.

Established the framework and approach to quality auditing of call center agents.  The approach centered around the concept of the three E’s (Economy, Efficiency and Effectiveness).  Developed audit tool that identified the problem and determined the 2 to 3 steps that can be improved.  The project included implementation of inter-rater reliability and a calibration process with a benchmark goal of 90%.  The quality program was designed to identify specific coaching opportunities and clear measureable scorecards. 

Developed policies and procedures to meet the State’s readiness assessment requirements.  Project included over 200 elements that comprised of the following areas: Appeals and Grievances, Member Communication, Medical Management, Quality, Claims, Reinsurance, Finance, Management Information System, Behavioral Health and Provider Network. 

Provided Medicaid expertise to support the submission of an integrated physical and behavioral health proposal. Contributed as a writer and particpated in the review process.  Prepared leadership team for the Oral Presentation component of the bid.  Client was awarded a contract. 

Performed an evaluation of a Medicare training program in an effort to improve Medicare knowledge within the organization.  The training manual was reconciled against CMS Manuals to understand gaps in training.  A full end to end review of the  training process was assessed and gaps were closed in curriculum design and program. 

Developed the annual plan for the EPSDT, Dental, Maternity Family Planning, Quality Management/Performance Improvement and Medical Management Plans that support the regulatory requirements and framework to monitor and evaluate performance. 

Provided guidance and instruction on how to implement Compliance 360 modules to manage compliance and State reporting. Developed workflow templates, processes and implemented the modules to include over 230 State deliverables. 

Set the strategic approach for performance improvement. Assessed workflows to identify key indicators to monitor and design comprehensive suite of reports. Established balanced scorecards with leading and lagging metrics. Collaborated with client to identify, profile and store data elements within the Enterprise Data Warehouse solution needed to effectively build suite of reports.  Utilized Tableau to hardwire the adoption of reports and analytics.  Trained the department and stakeholders across the organization on how to use Tableau and promoted system wide adoption.  

Reviewed and assessed the pharmacy determination process to understand causes of deficiency.  Corrected non-compliance and reengineered the workflow and standard operating procedures to stabilize Part D operations. 

Designed and developed the workflows for care management processes as set forth by contract requirements.  Highlighted the special health care needs and circumstances to be configured in the care management and care coordination systems.  Workflows included physical and behavioral health care coordination and step by step desktops. 

Designed and developed the workflow for catastrophic, reinsurance and transplant cases based on State regulations.  Led the leadership team through regulatory process and requirements. 

Peformed an evaluation of the process to produce Annual Enrollment Period (AEP) material for a matrix organization aimed to address deficiencies in the process, close the corrective action plan and safeguard from reoccurrence.  The team developed a custom AEP play book to ensure timely and accurate process.

Identified, assessed and developed talent amongst a newly formed team to ensure proper leadership transition was in place.  Coached and mentored team on job focused specific tasks through awareness, reflection, choice and action.  Established a succession plan for newly identified leaders with a highly structure 6-month mentoring program that included understanding and applying; different leadership principles, organization culture, individual behaviors, emotional intelligence, developing and leading teams, group dynamics, motivational foundations, individual and group decision making, managing conflict and managing change. 

Performed end to end assessment of Medicare contact center to identify cause of deficiencies and opportunities to improve.  Evaluated technology systems, IVR and training program.  All policies, procedure and workfows were reviewed and the Voice of the Customer was used to understand the member’s experience, set priorities and identify goals aligned to members’ needs and regulatory requirements.  

Led the redesign of the training department to improve retention, knowledge, employee engagement and patient satisfaction.  Assessed current state and developed learning objectives based on adult learning principles.  Led the redesign of the curriculum and training material based on collaborative feedback from managers and employees.  Established process to evaluate individual trainee performance through scorecards, quality auditing and coaching.  Benchmarks were established to support employee success.  Promoted the benefits of a thorough and comprehensive training program that fosters employee engagement and satisfaction. 

Provided guidance and expertise during member focus groups aimed to inform the development of Medicare plans and impact of brand awareness. Synthesized data and provided recommendations for new product design.