clinical quality consultant resume example with 9+ years of experience
JessicaClaire
, , 609 Johnson Ave., 49204, Tulsa, OK100 Montgomery St. 10th Floor
H: (555) 432-1000
C:
resumesample@example.com
Date of Birth:
India:
:
single:
:
Professional Summary
Highly motivated, goal-oriented registered nurse with 25 years of varied clinic experience and solid data review experience within a managed care environment. Adaptable and experienced in multiple areas of patient care and advanced technological skills to effectively manage and optimize health information systems. Collaborates effectively with multidisciplinary teams to accomplish dynamic initiatives and improves health systems and quality of care.
Skills
Self motivated and flexible working well independently or on a team
Organized, able to efficiently manage multiple priorities
Analytical, able to problem solve and make decisions
Teachable, able to learn, navigating new programs and databases
Perform detailed and accurate chart audits
Well versed in CMS regulations and NCQA tech specs.
Quality Management and improvement
Data interpretation
Adept at performing analysis and data interpretation
Operational budget forecasting
Medical claims coding
Work History
CLINICAL QUALITY CONSULTANT, 06/2019 - 12/2022 Accenture Contractor Jobs – Itasca, IL,
Assisted with new market start up in Iowa.
Maintained solid provider relationships and improved overall quality metrics of assigned Southeast Iowa clinics.
Monitored quality of reported data per HEDIS and NCQA guidelines.
Monitored changes in coding regulations to provide recommendations for compliance.
Verified diagnosis coding accuracy of patient information in medical records.
Performed abstraction and over read of medical charts.
Analyzed electronic health records to identify areas for care improvement and cost reduction.
Subject matter expert for Lead Screening measure; responsible for training and guidance of other analysts .and provider offices.
Monitor quality of reported data per HEDIS and NCQA guidelines.
Developed and maintained provider incentive earnings and payment for Quality department. Financial team liaison for quality team and provider payment.
Review monthly quality scores and provided feedback and education to provider offices.
Provided regular updates to team leadership on quality metrics by communicating consistency problems or production deficiencies.
Developed training materials, SOPs and work instructions to supplement new team member onboarding.
Sr. Clinical Quality Consultant II, 12/2016 - 06/2019 United Healthcare – City, STATE,
Performed review and extraction of documentation from medical records for HEDIS, prospective and concurrent reviews per NCQA standards.
Researched and analyzed claims histories, provider information, and validated data for the Medicaid Population.
Documented action plans and details of visits and reported critical incidents and quality of care issues.
Partnered with physicians and staff to explore new ways to encourage member clinical participation in wellness and education.
Completed tasks prior to deadlines and met quotas.
Collaborated with management to provide training on improved processes and assisted with creation and maintenance of quality training.
Developed and maintained quality assurance procedure documentation.
Provided regular updates to team leadership on quality metrics by communicating consistency problems or production deficiencies.
Developed training materials, SOPs and work instructions to supplement new team member onboarding.
Assisted with education of other staff, and over reads of abstracted data.
RN Community Based Case Manager, 12/2015 - 12/2016 United Healthcare – City, STATE,
Advocated for patients by communicating care preferences to practitioners, verifying interventions met treatment goals and identifying insurance coverage limitations.
Evaluated healthcare needs, goals for treatment, and available resources of each patient and connected to optimal providers and care.
Created patient assessments and plans for individual home care needs Of assigned 70+ cases.
Performed evaluations on consistent basis to address changes in patient needs, conditions and medications, altering care plans when required.
Liaised with physicians regarding patient needs, performance and changes.
Regional Director of Home Health, 09/2013 - 12/2016 Optimae Life Services - Nurse In The House – City, STATE,
Recruited, hired and trained all staff, providing direct supervision, ongoing staff development and continuing education to employees.
Established and maintained effective communication with staff, physicians and community organizations to promote high quality patient care.
Defined testing protocols, quality assurance initiatives and clinic policies and procedures.
Liaised with other healthcare professionals to develop comprehensive patient care plans and provide highest quality of care.
Designed and introduced leadership development, coaching and team management model, resulting in promotion of employees into increased levels of responsibility.
Conducted routine facility inspections, identifying areas needing improvement and eliminating hazards posed to staff and residents for continued compliance with associated regulations.
Education
Certified : Risk Adjustment Coder, Expected in 12/2019 - American Academy of Professional Coders - Salt Lake City, UT, GPA: Status -
Associate of Arts: Nursing, Expected in 05/1999 - Indian Hills Community College - Ottumwa, IA GPA: Status -
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