Alicia Shelton
Carrollton
Summary
Experienced Program Manager with a strong background in managing functional operations and projects related to supplies and logistics. Possesses advanced understanding of organizational strategies, financial management, procurement, and contracting. Skilled in logistical analysis, inventory and supply chain performance, development, and standardization. Demonstrates a thorough understanding of inventory management, procurement, and acquisition regulations. Detail-oriented individual with exceptional communication and project management skills. Proven ability to handle multiple tasks effectively and efficiently. Dedicated RN with a strong focus on delivering compassionate and patient-centered care. Highly skilled in coordinating care plans, managing patient stays, and ensuring efficient resource management. Collaborates with multidisciplinary teams to develop effective discharge plans. Proficient in providing comprehensive care and interventions in diverse environments. Capable of interpreting and communicating lab tests, conducting clinical patient assessments, and working with insurance providers. Committed to supporting quality improvement initiatives, including quality audits, HEDIS, STAR ratings in fast-paced environments. Recognized for taking a proactive approach to identifying and addressing issues, with a focus on optimizing processes and supporting team objectives.
Overview
12
12
years of professional experience
1
1
Certification
Work History
RN Program Manager
Molina Healthcare of Texas
11.2018 - Current
- Manage internal projects and programs with cross-functional teams, guiding them from strategy development through design to completion
- Monitor Clinical Operations projects with attention to planning, standardization, consulting, organizational change management, program management, and related business processes
- Acts as the subject matter expert in initiating and planning Clinical Operations projects
- Collaborates actively with internal stakeholders responsible for Clinical Operations to manage schedules and project budgets
- Leads discussions with leaders and other stakeholders to manage team planning and execution of new projects, ensuring consistent messaging, open communication, and obtaining buy-in
- Communicates and collaborates with internal and external customers to analyze needs and goals, transforming them into functional requirements
- Delivers required polished artifacts as needed
- Proficient in Microsoft Suite, particularly: Projects, Teams, Outlook, Visio, PowerPoint, Excel, and Word
- Analyzes data and trends to provide recommendations on project planning
- Validates business processes to ensure that the team stays on target
- Supervise and engage external vendors
- Ensures compliance with all policies and procedures
- Performs additional duties as reasonably provided by Molina to achieve the operational and financial success of the Company or Clinical Operations Department
RN Clinical Quality Consultant, II (PT Contract)
WellMed/Optum
05.2022 - 04.2023
- Drove the analysis of HEDIS/STAR rates, proactively identified barriers to improvement of rates and created interpretive exhibits, while supporting PCPs/clinics with quality data collection processes, conducting HEDIS record abstraction and extraction, retrieving/interpreting data from EPRG for data reporting, and partnering with leadership to define/execute quality strategies
- Led the coordination, implementation, and monitoring of QI and HEDIS interventions
- Engaged with PCP and clinic staff in developing strategies to close quality gaps, while managing/maintaining knowledge base of HEDIS/STARs standards and guidelines
- Extensive knowledge of current year outcome, process, and tracking measures along with FOC measures
- Facilitated conversations interdepartmentally within the health plan and visited provider offices to provide training on ways to improve HEDIS measure compliance and STAR rating improvement
- Assisted QM in implementing provider/member interventions, worked to remove barriers to care and produced reports on intervention progress and success rates; worked with IT on UAT
RN CONTRACT HEDIS/GPRO CHART REVIEWER
IntegraNet Health
11.2018 - 03.2019
- Led the extraction of HEDIS data at designated hospitals, specialty facilities and provider offices using current remote access databases and laboratory systems, facilitated/maintained remote access exchanges with health systems and providers, and followed established procedures for chart chases, data mining, scheduling, and the conducting of chart abstractions
- Coordinated/reported chart review schedule to team lead and provider network development; communicated abstraction processes, resources to complete abstractions and other concerns related to chart abstraction
- Collected/tracked data for quality monitoring/improvement and quarterly interrater reliability audits
LVN QUALITY COORDINATOR/SPECIALIST
WellMed-United Health
08.2017 - 10.2018
- Drove the analysis of HEDIS/STAR rates, proactively identified barriers to improvement of rates and created interpretive exhibits, while supporting PCPs/clinics with quality data collection processes, conducting HEDIS record abstraction and extraction, retrieving/interpreting data from EPRG for data reporting, and partnering with leadership to define/execute quality strategies
- Led the coordination, implementation, and monitoring of QI and HEDIS interventions
- Engaged with PCP and clinic staff in developing strategies to close quality gaps, while managing/maintaining knowledge base of HEDIS/STARs standards and guidelines
- Facilitated conversations with departments within the health plan and visited provider offices to provide training on ways to improve HEDIS measure compliance and STAR rating improvement
- Assisted QM in implementing provider/member interventions, worked to remove barriers to care and produced reports on intervention progress and success rates; worked with IT on UAT
LVN CONTRACT HEDIS/GPRO CHART REVIEWER
IntegraNet Health
01.2018 - 05.2018
- Managed the extraction of HEDIS data at designated hospitals, specialty facilities and provider offices using current remote access databases and laboratory systems, while following established procedures for chart chases, data mining, scheduling and chart abstractions
- Advised and educated providers and staff in the appropriate documentation of HEDIS and GPRO measures, medical record documentation guidelines and HEDIS ICD-9/10 CPT coding requirements
- Provided feedback regarding the abstraction process, resources required to complete abstractions and other concerns related to chart abstraction, while driving quarterly interrater reliability audits
LVN SPECIALIST, Quality Interventions/ QI Compliance
Molina Health Care Texas
07.2013 - 06.2017
- Managed and led the gathering and review of medical records from providers and facilities to complete activities related to quality-of-care issues, HEDIS and other quality improvement initiatives
- Developed P&Ps, workflows and required documents to meet federal and state regulatory requirements and NCQA accreditation, while performing analyses to identify and proactively resolve significant and problematic clinical issues and concerns
- Participated in NCQA accreditation and regulatory audit preparedness; prepared reports, narratives, graphs and charts as needed for external audits and surveys related to specific topic areas
- Implemented and monitored local QI and HEDIS interventions, created/managed documentation for QI compliance, and assisted intervention manager in implementing provider and member interventions
- Identified/reported any gaps in processes to the quality manager and director, and reviewed quality of care issues or activities related to medical record reviews that may require remediation or actions
- Visited provider offices for engagement training meetings to enhance ways to improve HEDIS measure compliance and STAR rating improvement; partnered in removing barriers to care
- Reported on intervention progress and success rates - served as a proctor for new QC hires
LVN/CARE REVIEW CLINICIAN I
Molina Health Care Texas
07.2013 - 06.2017
- Managed the review and verification of prior authorizations according to Molina policy, while determining appropriate benefits, eligibility and expected length of stay for members requesting new treatments or procedures
- Assessed services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations/guidelines
- Transitioned into specialty review as primary nurse reviewing all wheelchair authorization requests
- Analyzed clinical service requests from members or providers against evidence-based clinical guidelines; streamlined WC review process and created a 'provider satisfaction' approach to review
Education
Master of Science - Nursing Leadership and Administration
Capella University
04.2024
Bachelor of Science - NURSING
Capella University
04.2021
ASSOCIATE OF SCIENCE - NURSING
International College of Health Sciences
03.2018
VOCATIONAL NURSING CERTIFICATE -
E & K Vocational Nursing
05.1998
Skills
- Basic life support
- Skilled in Clinical Analysis
- Understanding Others
- Discharge planning
Software Knowledge
Microsoft Office (TEAMS, One Note, Co-pilot), Google Office, QNXT, UMK2, InterQual, LOCMS, Hayes, EncoderPro, QHSR, CMCM, Palantir, EPRG, Salesforce, DataRap, RightFax Operational, Tableau, ePRG, Jira, Power Bi, Clinical Care Advance, Touchworks, eClinical Works, ePic, NextGen, Athena, Allscripts, Practice Fusion, Glacer
Professional Qualities
- Compassionate
- Empathetic
- Patient-focused RN experienced in delivering/promoting all aspects of total patient-centered care via coordination of care plans focused on appropriate treatments and patient stay
- Managing the length of stay
- Ensuring appropriate resource management
- Developing appropriate discharge plans in collaboration with multidisciplinary teams
- Well-versed in providing care and interventions to patients in diverse environments utilizing a comprehensive, multidisciplinary approach
- Interpreting and communicating lab tests
- Conducting clinical patient assessments
- Collaborating with insurance providers
- Supporting QA/improvement initiatives related to quality audits, HEDIS, STAR rating and NQCA Accreditation
Certification
BCLS, CCM
Timeline
RN Clinical Quality Consultant, II (PT Contract)
WellMed/Optum
05.2022 - 04.2023
RN Program Manager
Molina Healthcare of Texas
11.2018 - Current
RN CONTRACT HEDIS/GPRO CHART REVIEWER
IntegraNet Health
11.2018 - 03.2019
LVN CONTRACT HEDIS/GPRO CHART REVIEWER
IntegraNet Health
01.2018 - 05.2018
LVN QUALITY COORDINATOR/SPECIALIST
WellMed-United Health
08.2017 - 10.2018
LVN SPECIALIST, Quality Interventions/ QI Compliance
Molina Health Care Texas
07.2013 - 06.2017
LVN/CARE REVIEW CLINICIAN I
Molina Health Care Texas
07.2013 - 06.2017
Bachelor of Science - NURSING
Capella University
ASSOCIATE OF SCIENCE - NURSING
International College of Health Sciences
VOCATIONAL NURSING CERTIFICATE -
E & K Vocational Nursing
Master of Science - Nursing Leadership and Administration
Capella University
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