Experience

• 

  Optum

  • United States
  • Hospitals and Health Care
  • 700 & Above Employee

  • Director Delegation Oversight | Optum West Region (Mountain West, Oregon, Washington)

    • Aug 2023 - Present

  • Associate Director, Quality Medical Management

    • Apr 2023 - Sep 2023

    Associate Director, Quality and Training for Optum Care Network Arizona Medical Management

  • Sr. Clinical Quality Nurse

    • Aug 2022 - Apr 2023

• 

  UnitedHealthcare

  • United States
  • Hospitals and Health Care
  • 700 & Above Employee

  • Senior Clinical Program Manager-Delegation oversight regulatory

    • Apr 2019 - Aug 2022

  • Senior Clinical Quality Nurse

    • Dec 2014 - Apr 2019

    Clinical Business Performance Oversight|Delegation Adherence & Performance Improvement• Serve as a clinical liaison responsible for scheduling, conducting and documenting annual audits, improvement action plans (IAP) and reaudits of HMO Commercial, Medicare Advantage and Medicaid delegated contracted Medical Groups and IPAs within regulatory driven timeframes. Business travel as necessary to Medical Groups.• Working with internal regulatory & compliance regarding Medical group audit issues and when audited by internal and external regulatory accredited bodies, including CMS, DMHC, and NCQA.• Responsible for communication of audit results, both verbally and in writing internally and externally. Includes communication with Medical Directors, UM & QI Departments internally and externally.• Responsible for educating/training the provider groups to influence their behaviors that impact compliance regarding clinical processes, denial letters and all NCQA standards and regulatory requirements. Creating correspondence, presentations and talking points intended to document findings of studies and communicate results and suggested improvement action plans.• Conducting analysis of information, interpreting provider results and providing feedback and making recommendations for improvement. Monitoring monthly & quarterly performance of assigned medical groups through reporting including appeals & grievances, ER denials, referrals, Provider profiles, quarterly UM and QM reports and other data generated internally and externally for the delegated provider groups.• Assist with data collection, organization, analysis and follow-up to support QI programs.• Assist with creation of process and procedures as necessary for inter-rater reliability alignment.

• 

  OptumHealth

  • Transplant Case Manager

    • Feb 2013 - Dec 2014
• 

  Principal Financial Group

  • United States
  • Financial Services
  • 700 & Above Employee

  • Medical Management Nurse Supervisor

    • Apr 2005 - Jun 2012

    Provided management and development for up to 12 exempt/non-exempt staff members including transplant case managers, transplant claim specialists, case managers, benefit managers, and non-clinical staff to meet client's health needs and promote quality cost-effective outcomes.

  • Transplant Case Manager

    • Nov 2002 - Apr 2005

    Provided proactive transplant case management for members throughout their continuum of care to meet established goals. Support included: education, transplant claim support and steerage to network providers.

  • Utilization Management

    • Jul 2001 - Nov 2002

    Responsible for completion of utilization reviews for self-insured member population.

• 

  The University of Iowa Hospitals and Clinics

  • Iowa City, Iowa Area

  • RN Staff Nurse

    • Feb 1992 - Jul 2001
    • Iowa City, Iowa Area

    Provided Nursing support for the Pediatric population in hematology and oncology, gastrointestinal, renal, urology, neurosurgery, solid organ transplant (liver and kidney) and pediatric trauma.