Quality Management Manager Accreditation resume example with 20+ 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:
Summary
Meticulous and knowledgeable Healthcare Professional with a 25-year record of success in Managed Care, Utilization Management and Quality Management focusing on policy development, program management, risk mitigation and audit submissions. Proficient in maintaining regulatory compliance and correcting systemic issues in collaboration with business managers. Team-focused, consistent and diplomatic with a focus on building strategic alliances and enhancing company standing.
Consistently achieved exemplary NCQA and various regulatory audit submission results.
Implemented quality improvement activities and member satisfaction interventions resulting in improved clinical outcomes and member satisfaction.
Manager with over 20 years of experience directing staff and maintaining a positive, productive environment.
Skills
Strong Work Ethic
Customer Service
Attention to Detail
Time Management
Critical Thinking
Team Collaboration
Effective Multitasking
Process Documentation
Complex Problem Solving
Employee Training
Interpersonal Communication
Team Management
Experience
Quality Management, Manager - Accreditation, 09/2010 - Current Crawford & Company – Salt Lake City, UT,
Successfully organized and led the NCQA Commercial product accreditation survey process resulting in exceptional results.
Collaborated with the Compliance Department and submitted QPH documentation with optimal results.
Executed successful compliance monitoring and risk assessment programs.
Managed business functions, clinical services and programs to meet and comply with regulatory agencies' accreditation standards, program regulations and payer requirements.
Created and implemented training programs to maintain accreditation standards and for employee development.
Developed the annual Quality Management Program Description, Program Evaluation and Work Plan. Maintained the documents and updated them to ensure identified initiatives are on target.
Investigated reported and identified compliance issues against accepted standards.
Maintained detailed database of compliance data, activities and actions taken.
Stayed up to date on relevant processes and compliance standards for optimal oversight.
Implemented training programs to maintain accreditation standards and for employee professional development.
Managed business functions, clinical services and programs to meet and comply with regulatory agencies' accreditation standards, program regulations and payer requirements.
Built positive working relationships with other department employees through effective communication.
Successfully managed a staff who assisted with the accreditation submission process.
Collaborated extensively with the Legal Department to ensure delegates and vendors included regulatory compliance initiatives/requirements within their contracts.
Prepared the Accreditation team's budget related to staffing, external audits, consultant management and accreditation responsibilities.
Led new product implementation initiatives on behalf of Quality Management.
Attended all committee meetings on behalf of Quality Management.
Medical Case Manager, 01/2009 - 09/2010 Healthfirst – City, STATE,
Collaborated with various healthcare providers to facilitate delivery of services for the Medicare and Medicaid populations.
Reviewed treatment plans against individual goals and healthcare standards.
Collaborated with healthcare teams to improve care quality, reduce costs and gauge patient progress.
Maintained confidential case documentation.
Performed pre-admission, concurrent and retrospective reviews in order to evaluate the appropriateness of admissions, need for continued stay, length of stay and utilization resources.
Modified treatment plans to accommodate changes in clients' health or progress.
Educated clients on options to assist in making informed decisions.
Informed patients and families of treatment options, medications and at-home care strategies.
Director, Clinical Healthcare Operations, 05/1997 - 11/2008 HIP Health Plan Of NY/Emblem Health – City, STATE,
Prepared, organized and presented documentation demonstrating NCQA and URAC accreditation compliance resulting in excellent results.
Prepared Care Management's materials and documentation for submission for the Centers for Medicare and Medicaid Services audits.
Developed the annual Care Management Utilization Management Program Description, Program Evaluation and Work Plan.
Developed and implemented policies and procedures for the Care Management Administration. Validated and monitored adherence to the implemented policies.
Represented Care Management at various committee meetings.
Assisted with the development of the department budget.
Contributed to organizational strategic direction to improve products and services.
Worked with management team to develop operational goals aligned with business strategy.
Set goals and expectations for direct reports using performance review process, holding staff accountable.
Education and Training
Bachelor of Science: Nursing, Expected in - Georgetown University - Washington, DC GPA:
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