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Registered Nurse and Certified Professional Healthcare Quality (CPHQ)
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