Expert Details
Healthcare Quality - Accreditations, Compliance and Structure (Facility and Provider Practices)
ID: 736682
Texas, USA
Created/implemented clinical OPS infrastructure/budgets for 11 MCOs, physician practices, and hospitals
. Achieved successful Joint Commission accreditations for cardiovascular hospital and 2014 Corporate Mock Survey for behavioral health hospital
. Created Center of Cardiovascular Excellence: awarded Top 100 Solucient Hospital, first Health Grades award, recognition for Citywide AHA Get With the Guidelines as Southern Region spokesperson; integrated GWTG into Case Management Dept.
. Assumed responsibility for Case Management staff; initiated dept. infrastructure, budgeting, policy and procedure, use and education review criteria
. Behavioral Health – restructured UM department into formal Care Coordination model.
. Implemented MCO relationship-building through cross-company education/interaction and understanding of multiple and conflicting MCO Admission and LOS criteria sets. Further reduced UM denials by 85% through implementation of provider documentation standardization (approximately $1M recoupment).
. Increased cash flow 60% by reducing UM Appeals from a historical backlog
. Researched/authored standardized Order Sets adopted by two major hospital systems
. Improved by 62% Safety Program compliance in large 18 clinic physician practice
. Reduced many pending lawsuits to 0 as liaison for all depositions, lawsuits, mediations Texas Medical Board, liability carrier, and attorney issues
. Developed Fair Hearing & Due Diligence processes with Health Law attorney; developed Health Plan documents for legal approval and client guidance
. Led migration of credentialing from paper to 100% paperless, electronic process
. Authored 105 initial corporate Policy and Procedures and Clinical Guidelines
. Developed 16 sets of physician Annual Clinical Privileging Criteria
. Defined Quality Metrics for EMR conversion; implemented turnaround times compliance under Federal, State, and Local standards of practice; reduced all CV imaging turnaround times to <24 hours in both hospital and physician organizations with transparent compliance reporting
. Completed Clinical Services re-organization for very large (320+) physician practice.
. Facilitated new EHR use solutions to assure data retrieval for PQRS and “meaningful use”.
. Partnered with IT to create transparency-based QI reporting companywide as first-ever reporting in a 14-office physician practice
. Authority for National Registry, federal and state reporting; Administrator, proprietary/public national databases
. Created production, CME, and competency tracking/reporting previously non-existent
. Initiated contract review process with Finance Dept. to limit liability exposure; implemented validation of regulatory reports, oversight of vendors/ contractors
Education
| Year | Degree | Subject | Institution |
|---|---|---|---|
| Year: 1965 | Degree: Associates of Arts, Associate Registered Nurse | Subject: Nursing and Business | Institution: SR School of Nursing |
Work History
| Years | Employer | Title | Department |
|---|---|---|---|
| Years: 2019 to Present | Employer: Undisclosed | Title: Lead | Department: Loss Prevention |
Responsibilities:Opened and provisioned a new 70,000 sq. ft store with accountabilities for Loss Prevention and leadership. COVID pandemic ended the public-facing position |
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| Years | Employer | Title | Department |
| Years: 2014 to 2018 | Employer: United Healthcare, Texas Health Plan | Title: Director | Department: Quality and Compliance |
Responsibilities:Key liaison with the State of Texas for contract compliance across all lines of business; reporting initially as special projects for Senior Dir. of Quality followed by promotion to Associate Director of Compliance. Subject Matter Expert for Population Disease management software with a nationally recognized tech company, designed Best Practice clinical dashboards, supported clinical/analytical data research and reporting including Potential Preventable Events, QIPP for Skilled Nursing, Pay 4 Quality and Value-Based Contracting projects. Liaison for Texas Medicaid RFPs. |
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| Years | Employer | Title | Department |
| Years: 2017 to 2018 | Employer: UHS Inc. Meridell Achievement Center | Title: Director Quality, Risk and Privacy Officer | Department: Quality, Risk Management and Care Coordination |
Responsibilities:130 bed residential pediatric behavioral health center (11 buildings). Prepped organization and physicians for Joint Commission survey. Cured Appeals backlog and reduced denial rate to <2% save $1M within 6 months. Developed first-ever Medical Staff leadership quality reporting and risk management program; conducted 22 DFPS investigations including 5 Sentinel Events with Root Cause Analysis. Managed staff of 3 Utilization Management staff |
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| Years | Employer | Title | Department |
| Years: 2002 to 2017 | Employer: Heart Hospital of Austin and Austin Heart PLLC | Title: Director of Quality and Risk | Department: Cardio Vascular |
Responsibilities:Created the quality program for new CV hospital and won Solucient Top 100 and Health Grade awards. Implemented the Austin, TX citywide American Heart Association Get With the Guidelines program and became Southern Region spokesperson. Led hospital through 2 successful Joint Commission surveys and went on to create the gold standard CV program for 14 Central Texas clinics (70 providers). Achieved the first Triple Accreditation for CV imaging in Texas. Closed 24 potential lawsuits in the first year with no lawsuits brought during my tenure. Authored with physicians 20 privileging guidelines and conducted annual privileging which exceeded all credentialing criteria adopted by 2 hospital systems. Co-Authored many clinical order sets for all embedded programs |
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Career Accomplishments
| Licenses / Certifications |
|---|
| Texas RN 2023 CPHQ 2021 pending renewal to 2024 |
| Awards / Recognition |
|---|
| Health and Human Services Commissioners Award for creation of an HMO clinical intra state council |
| Medical / Professional |
|---|
| Additional: *Director Quality Improvement, Humana, Inc., Austin, TX - 250,000 HMO and PPO members; staff of 9 regional experts *Manager Quality Management, NYLCare /Aetna U.S. Healthcare, Austin TX- created Quality and Risk position for start-up HMO founded by New York Life: successfully acquired by Aetna. *Manager Health Services Division, EDS/NHIC Managed Medicaid STAR Health Plan, Austin TX – created State of TX Health Services Division for managed care pilot with 1 HMO in Travis County and PCCM model in 3 south TX counties. Hired 35 RNs and automated entire Quality and UM processes. *Consultant National, Managed Care, West Hudson & Co, Los Angeles, CA; Hospital performance consulting *Director Pediatric Rehab Program, Dallas Rehab Institute, Dallas, TX – built out 13-bed pediatric rehab unit/wing for severely injured children with Traumatic Brain Injury; hired/led 24/7 multidisciplinary treatment team *Administrator HMO Medical Management, Aetna Health Plans, Dallas, TX *Co-Founder Pacific Mental Health Plan, Novato, CA and Consultant Health Plan of the Redwoods, Santa Rosa, CA *Director Utilization and Claims Administration, Los Angeles Foundation for Medical Care/LA County Medical Assn. and CIGNA Health Plans – dynamic Chief for 24 nationally recognized physician specialists to design and implement TQM/UM processes for IPA; oversaw the creation of CA RVS system adopted by Blue Cross/Blue Shield of California and CIGNA. *Director of Provider Relations United Ins. Corp. of America, Los Angeles, CA *Admitting Nurse/UM, Northridge Hospital Medical Center, Northridge, CA *Practicing RN, Medical, Surgical, CCU, OBGYN, Labor and Delivery, ICU, CCU |
Additional Experience
| Marketing Experience |
|---|
| As Director of Pediatric Rehab Program, accountable for revenue through marketing the hospital and program services in Central Texas. |
| Other Relevant Experience |
|---|
| Able to create collaborative and dynamic clinical program implementations with physicians and other providers. |