Dane County, Wisconsin, United States
Accomplished HealthCare Quality Improvement Leader with expertise in Performance Measurement , Community Outreach, and Coordinating Government Program and HEDIS audits; Designing, implementing, and evaluating quality improvement initiatives to improve the health of both members and the community; Managing HEDIS medical record review, Community Health Needs Assessment, and Community Benefit Reporting.
•Lead the development and monitoring of the health plan’s Quality Improvement (QI) and Utilization Management (UM) Program Description, Quality Improvement and Health Equity Work Plan, and QI and UM Program Annual Evaluation. •Project managed the launch of the new organizational quality committee and subcommittee structure to ensure NCQA and regulatory best practices are implemented, included partnering with committee chairs to ensure oversight of applicable quality program activities and analyses. •Supported the coordination of Quality Committee processes, served as the chair of the Quality Performance and Improvement Committee and oversaw the NCQA support for the Care and Utilization Management Committee and Population Health and Health Equity Committee and subcommittees. •Facilitated quality cross-divisional projects, including a HEDIS end-to-end improvement project, the integration of quality of clinical care and service complaint investigation processes, and development of the 2025 Stars Action Plan monitoring and communication processes. •Facilitated process improvement and integration efforts for the Quality Program Operations Department. •Mentored and coached staff responsible for developing an integrated, standardized process for investigating and monitoring quality-of-service complaints, and NCQA best practices outlined in UM and PHM Standards.
•Managed the NCQA Accreditation team responsible for successfully achieving NCQA Health Plan Accreditation for commercial, Medicaid, and Individual and Family business in multiple states through renewal, first, and interim surveys. These efforts included developing a roadmap and monitoring NCQA survey readiness. •Oversaw efforts to achieve NCQA Health Equity Accreditation for the Health Plan’s Medicaid population. •Lead the HEDIS Reporting team responsible for all required NCQA and CMS quality data submissions for all eligible lines of business, including the reporting of audited HEDIS, CAHPS, Enrollee Experience Surveys, and HOS submissions. •Built strong and cohesive teams by facilitating a positive and collaborative work environment that embraced continuous improvement and supported efforts leading to high quality performance across products, including achieving 5 Stars in our Medicare Advantage Plan for multiple years. •Supported strategic program development, implementation, ongoing performance evaluation and continual process improvement for the Quality Management Department. •Coordinated with all functional domains of the Quality Department to ensure strategic alignment, transparency, and standardization; Facilitated cross-functional meetings to ensure appropriate prioritization of initiatives and implement a continuous cycle of improvement. •Collaboratively developed and monitored the Health Plan’s Quality Improvement Program Description, Quality Improvement Program Work Plan, and Annual Quality Program Evaluation. •Coordinated and supported the Health Plan’s Quality Improvement Committee structure. •Developed and implemented an organizational structure that supported NCQA survey readiness and ensured NCQA Health Plan and Health Equity Accreditation. •Mentored and supported staff in the initial creation and ongoing maintenance of quality program documentation including, project charters, policies and procedures, work plans, and training materials.
•Coordinated the portfolio of quality activities and initiatives designed to drive improvements in provider engagement, clinical care, data integrity, customer satisfaction, and communication with members and providers. •Engaged and collaborated with stakeholders across the organization to develop and implement strategies to engage, educate, and motivate providers and internal stakeholders to positively impact Health Plan Ratings, including CMS Star ratings, and quality performance. •Effectively monitored and communicated performance progress, new initiatives needed for improved performance, and organizational barriers. •Coached and mentored Quality Improvement Specialists responsible for the implementation, monitoring and evaluation of quality improvement initiatives. •Analyzed and evaluated results of quality improvement strategies to report findings to leadership, regulatory organizations, internal and external stakeholders. •Developed and deployed quality performance dashboards and transparency tools to effectively monitor and communicate performance progress to upper management •Developed and implemented tools and templates to support the design, implementation, and evaluation of quality initiatives.
•Lead a multi-disciplinary team in the design, implementation, and evaluation of the PHM Strategy. •Coordinated program development in partnership with providers, health systems, and community organizations. •Project managed new strategic quality initiatives and monitor work across the teams. •Served as a Quality Management representative on system teams such as the Community Integration Workgroup and Iris Behavioral Health Implementation team. •Collaborated with the leadership team to develop strategic priorities for achieving the DHP’s quality goals. •Analyzed and evaluated results of quality improvement strategies to report findings to leadership, regulatory organizations, internal and external stakeholders. •Developed process documentation for Population Health Management and quality improvement initiatives. •Assisted other teams with developing work plans and strategies for prioritization and risk identification. •Monitored assigned NCQA standards to ensure health plan processes are in line with best practices.
As the Community Relations Consultant I had the following responsibilities: •Monitored and reported on SSM Health's Community Health Needs Assessment (CHNA) priorities and goals in Dane County. This included compiling data and reporting the Strategic Implementation Plan (SIP) goals and efforts. •Chaired 5 different multidisciplinary teams that acted as advisory groups for community benefits and each of the goals under the three CHNA priority areas. •Partnered with not-for-profit organizations in our community to improve health in three CHNA priority areas; Mental Health, Chronic Disease (specific to hypertension and type II diabetes), and Maternal/Child Health. These partnerships included Second Harvest Food Bank to implement the Diabetes Wellness Program, Wisconsin Women's Health Foundation with the First Breath Families Program, Rebalanced Life Wellness Association to open the first Men's Health and Education Center connected to JP's Barbershop, and Catholic Charities to offer mental health programming in schools in rural areas. •Collected and reported over $16 million in Community Benefit Activities for SSM Health entities in Dane and Sauk Counties. This included St. Mary's Hospital-Madison, St. Clare Hospital, Dean Health Plan, and Dean Medical Group. •Represented SSM Health on the Healthy Dane Collaborative, The Health Council, and the Triangle Community Ministry Board. •Coordinated a monthly mobile food pantry in the Triangle neighborhood where approximately 20 volunteers unloaded a Second Harvest truck, set up the pantry, helped over 100 households shop for food in an hour, and cleaned up.
Healthcare Effectiveness Data and Information Set (HEDIS) reporting: • The training, coordination, and evaluation of 15-30 HEDIS medical record reviewers • Organizing the annual HEDIS audit, which included the compilation and submission of the HEDIS Roadmap, responding to auditor questions, the coordination of the onsite audit, and the Medical Record Review Validation (MRRV) process. • Ensuring the accuracy of the data collection process by performing primary source validation audits and working with clinics to resolve data issues. Measure Monitoring and Prioritization: • Compiled quality reports to monitor HEDIS and CAHPS (Consumer Assessment of Healthcare Providers and Systems). Reports were used to prioritize and develop strategies for improvement Efforts • Facilitated cross-divisional teams to develop improvement strategies, perform root cause analyses, and create evaluation & measurement plans. • Planned, developed, implemented, and evaluated new interventions designed to improve priority measures. • Worked to improve community and provider engagement to improve quality rates by participating in community groups like the Dane County Immunization Coalition (DCIC), the Southern Wisconsin Immunization Consortium (SWIC), and the Wisconsin Chronic Disease Project. • Coordinated the Quality Improvement Provider Pilot program and facilitated routine provider site meetings which were key to strengthening partnerships and improving measures.
Leadership & Management • Coordinated BadgerCare Plus Pay for Performance Programs Implemented by the State of Wisconsin. • Managed the BadgerCare Plus Healthcheck Program • Coordinated the development, implementation, and submission of two annual Performance Improvement Projects • Maintained provider manuals for BadgerCare Plus programs to ensure accuracy of information related to quality Community, Provider & Member Engagement • Developed outreach and educational materials used to conduct provider training • Acted as a liaison to the Department of Health Services, local health departments, healthcare providers, and community organizations • Represented the Government Programs Department on internal committees and community coalitions • Maintained and monitored Memorandums of Understandings with local health departments, Madison Metropolitan School District, Janesville School Districts for healthchecks, immunizations, and blood lead testing. • Served as a back-up advocate for BadgerCare Plus members who needed assistance with navigating the healthcare system Analysis • Analyzed data to assist in the development of both provider and member interventions • Monitored outreach efforts to meet BadgerCare Plus Core Plan physical and reporting requirements
Leadership & Management • Managed Dean Health Plan’s Healthcheck Program • Developed outreach efforts to meet healthcheck goals and avoid financial penalties • Managed the Memorandum of Understanding with the Madison Metropolitan School District for healthchecks Community, Provider & Member Engagement • Represented Dean Health Plan on community based coalitions • Conducted provider education needed to meet healthcheck goals • Performed back-up advocate duties for BadgerCare Plus members needing assistance with navigating the healthcare system. • Developed and maintained member outreach materials distributed by Dean Health Plan Data Analysis • Analyzed healthcheck, immunization, and blood lead data to ensure that quality goals were met and penalties avoided • Wrote and submitted Dean Health Plan’s two Performance Improvement Projects