quality improvement specialist resume example with 17+ years of experience

Jessica Claire
, , 609 Johnson Ave., 49204, Tulsa, OK 100 Montgomery St. 10th Floor
Home: (555) 432-1000 - Cell: - - : - -
Professional Summary

Operations leader in strategic planning, procurement management, patient services, utilization, policies, human resources, revenue cycle management, compliance, call center and development, logistics, HRIS, human capitol, budget prep and transportation management, customer service, fleet management, Medicare, Medicaid, medical billing and developing , professional experience with state/local Dept. of Social Services, Behavioral Health & Disabilities Services, Managed Care Organizations, FQHC Services, Mental Health Services, Case Management Services, Healthcare Systems, Ambulatory/Primary Care! Claims, payments & collections, Operations and Healthcare Finance Administration. Expert in accounting, auditing, IT Support, project management for large complex projects, programs operations, management of teams, negotiations, procurement, strategic planning, administration and management, quality outcomes for customers, employees and developing relationships with public stakeholders. Professional credentialing and accreditation administration for approved PACE/CARF/CHAP/JCAHO/COA environments. Notary.

  • Performance optimization
  • Profitability improvement
  • Application of GAAP regulations
  • Process improvement
  • Change management
  • SAP expertise
  • Data trending knowledge
  • Regulatory compliance
  • Pricing and costing
  • Data collection and analysis
  • Contract management
  • Project management
  • Financial leadership
  • Quality Assurance
Work History
10/2020 to Current
Quality Improvement Specialist Visiting Nurse Service Of New York Atlantic Beach, NY,
  • Developed quality improvement plans, policies and operational guidelines.
  • Documented and reported issues with compliance, standards of care and quality assurance requirements.
  • Assessed ongoing operations against standards.
  • Compiled review data and produced detailed reports for use by DBHDS data warehouse teams, KPA stakeholders to improve compliance indicators to 86%.
  • Evaluated competences of CSB case management staff, documenting ISP performance metrics and recommending improvements.
  • Completed site visits to conduct onsite audit reviews.
  • Applied knowledge of data outcomes to make insightful observations of deviations and successes.
  • Collaborated with CSBs to apply root cause analysis guidance and establish effective planning techniques.
  • Tracked quality issues for external stakeholders to enhance support operations.
  • Applied guidance techniques and tools for case managers and team members for improving performance.
  • Recorded, analyzed and distributed statistical information.
  • Evaluated interactions between internal teams and to assess personnel performance and implement strategies for external guidance for improvement.
  • Maintained current initiatives by participating on projects teams.
  • Scheduled and chair quality review meetings to review effectiveness of performance mitigating risk, improving throughput and achieving DOJ reviews satisfaction.
  • Evaluated interactions between providers to assess performance and implement strategies with interdepartmental improvement.
04/2018 to 07/2019
Director of Long Term Services Point32health, Inc Providence, RI,
  • Skillfully managed daily 2600 MLTSS Network providers. Development operations as functioning Director for multi-million dollar healthcare MCO.
  • Demonstrated ability to lead and motivate outstanding healthcare teams
  • Lead planning and achievement of goals and objectives consistent with organizational mission and philosophy
  • Initiated audit process to evaluate thoroughness of documentation and maintenance of accounts
  • Strategically planned methods to achieve operational goals and targets
  • Educated staff on state and federal statutes, rules and regulations governing all lines of services for provider communities
  • Developed and achieve outstanding claims for high volume in-network providers
  • Liaised between provider network and internal teams to ensure resolution for provider relation issues
  • Reviewed customer survey information to prioritize areas of improvement
  • Confidently managed overall operation of quality assurance, quality index scores
  • Lead management staff and provider service representatives in producing business plan MLTSS focused
  • Maintained line of business trends activities
  • Communicated regularly with territory, regional and strategic managers for daily support and strategic planning for accounts
  • Set up service agreements for rate enhancement request provider feedback
  • Reinvented how team interacts with provider communities
  • Collected information about rejected claims and developed effective solutions
  • Investigated issues to determine appropriate path for payment claims
  • Researched and resolved issues regarding integrity of data flow into databases
  • Handled claims consistent with client and corporate policies, procedures, best practices and regulations
  • Documented and communicated all claim reimbursement activity timely and effectively for outcome of claim files
  • Followed up with service providers on unresolved issues
  • Met with service provider and business partners to offer support with contracts, credential, claim issues
  • Followed up with customers on unresolved issues
  • Identified process improvements in day-to-day
  • Provided service provider education
  • Achieved retention through effective communication, problem resolution, proactive supervisory practices and facilitating proactive work environment
06/2003 to 07/2018
Chief Operations Officer Evergreen Healthcare Services Inc. City, STATE,
  • Worked with EHS on project from July, 2019 to Oct. 2020 for MCO project independently while caring for parent
  • Oversight hiring and training policies for new senior managers
  • Established and updated business procedures
  • Developed key initiative projects that drove substantial business growth
  • Cultivated forward-thinking, performance producing business culture
  • Developed and implemented strategic policy
  • Negotiated and finalized all organizational contracts
  • Partnered successfully with state and local authorities to produce business acquisitions
  • Approved education, communication and support for center staff, patients, employees
  • Coordinated in house and contracted services including meals, transportation, home care, housekeeping, medical services, equipment to ensure quality, safety, and compliance.
  • Ensured adequate staffing appropriate to levels
  • Knowledge of health care delivery systems, regulations, quality assurance for medical and non-medical patient coordination
  • Tracked data up/down trends and suggested enhancements to challenge and refine company's value-based performance initiatives
  • Increased profits by 60% in 4 year cycle through reimaging brand, and line of business
  • Provided DHS (Department of Health Services) with corrective action plans
  • Consistently complied applicable laws and regulations and ensured facility adhered to Medicare and Medicaid regulations
  • Authorized expenditures account, established service rates and coordinated financial reporting
  • Cooperated and communicated effectively with physicians, medical staff to ensure patient satisfaction
  • Coordinated with other internal departments & partnerships to merge services
  • Maintained healthy partnerships with governing boards
  • Reviewed departments performance metrics & consulted with senior leadership
  • Approved marketing for public awareness
  • Delivered customized and solutions
  • Implemented innovative employee loyalty and employee reduction incentive plans
  • Increased utilization by 100% across multiple departments
  • Drove operational direction, administrative and cost efficiency to ensure operational security
  • Met patient care and provider services standards Gold Star
  • Supported business growth through strategic planning and process development
  • Reduced budgetary expenditures by effectively negotiating contracts for more advantageous terms
  • Oversight on-boarding recruitment, hiring and training, key Performance Indicators and compensation analysis
  • Oversight HR operations, strategic workforce plan, goal cascading, performance management, and benefits administration
  • Applied performance data to evaluate operational targets for current business acumen
  • Reviewed financial statements and reports to evaluate AR performance, developed targeted improvements for change management
  • Launched employee engagement, gender diversity and cultural programs to improve retention
  • Evaluated suppliers to assess quality, timeliness and compliance of deliveries, maintained tight cost controls and maximized business operational efficiency
  • Spearheaded overhaul of programs/services
  • Chaired weekly meetings with executive leadership to identify opportunities for improvement, established milestones and tailor products to regional markets
Expected in 2006 to to
Master of Science: Education
American Intercontinental University - Schaumburg, IL
Expected in 1999 to to
Bachelor of Science: Human Services
Slippery Rock University of Pennsylvania - Slippery Rock, PA


Virginia Public Notary, Expiration 2024

By clicking Customize This Resume, you agree to our Terms of Use and Privacy Policy

Your data is safe with us

Any information uploaded, such as a resume, or input by the user is owned solely by the user, not LiveCareer. For further information, please visit our Terms of Use.

Resume Overview

School Attended

  • American Intercontinental University
  • Slippery Rock University of Pennsylvania

Job Titles Held:

  • Quality Improvement Specialist
  • Director of Long Term Services
  • Chief Operations Officer


  • Master of Science
  • Bachelor of Science

By clicking Customize This Resume, you agree to our Terms of Use and Privacy Policy

*As seen in:As seen in: