Aracelys Martin
Pembroke Pines,FL
Summary
Results-driven leader with background in executive leadership. Utilizes innovative approaches to drive business growth and operational excellence. Track record of effective team collaboration and achieving results.
Overview
23
23
years of professional experience
1
1
Certification
Work History
VICE PRESIDENT OF HEALTH SERVICES & QUALITY IMPROVEMENT
Clear Spring Health
01.2017 - Current
- Lead strategic and operational oversight of Health Services (Care Management and Quality Departments). Focus on CMS compliance, STAR Ratings performance and accreditation readiness.
- Manage Quality Improvement initiatives across multiple markets, including: CAHPS and HOS survey implementation with full vendor oversight and implemented target initiatives to improve member’s response rate to survey with a successful increase of 10% in a year.
- Chronic Care Improvement Program (CCIP) management/oversight
- Full lifecycle management of HEDIS project and audit.
- Analyzed CMS Star Rating metrics to identify performance gaps and developed targeted actions plans, contributing to STAR rating increase over 2 years.
- Implemented CMS SNP Model of Care Program for dual-eligible and chronic condition members, provided ongoing oversight and ensured 100% CMS audit readiness.
- Founded and chaired the STARs Steering Committee and subcommittees improving cross functional execution of quality KPIs and driving STARs rating Improvement Plan.
- Led initiatives to enhance member retention, satisfaction and engagement- Wellness Incentive Program.
- Established the Enrollee Advisory Committee and facilitated its transition to Customer Service to strengthen member-centered care.
- Collaborated with Network Management in the Pay-for-Performance (P4) Incentive Program to drive quality outcomes.
- Chaired the Quality Improvement Committee, reporting to the Board of Directors and overseeing multiple quality-focused subcommittees.
- Ensure patient safety through the systematic review of hospital-acquired conditions (HACs), never events, and inpatient mortality.
- Applied comprehensive knowledge of federal and state regulations, along with requirements from nationally recognized accrediting bodies.
- Managed multiple vendor performance to ensure alignment with contractual obligations.
- Oversight of Health Services and Quality departments operational budgets.
- Develop and implement employee training and mentoring programs to strengthen team capabilities and leadership development.
VICE PRESIDENT QUALITY IMPROVEMENT
Independent Living Systems (ILS)
01.2014 - 01.2017
- Company Overview: A national Third-Party Administrator (TPA) specializes in Medicare and Long-term care support services for health plans and government programs.
- Directed cross-functional teams and departmental operations in partnership with the COO for major health plans including Humana (IL/FL), LA Care, iCircle NY, and Kaiser Permanente Hawaii.
- Established and operationalized the Credentialing Department, successfully implementing CACTUS software to streamline provider onboarding.
- Built and led the Quality Improvement and Credentialing departments, designing and implementing key operational programs— including Quality Improvement, and Care / Utilization Management ensuring alignment with organizational strategy and regulatory requirements.
- Oversaw multiple departments across markets: Quality Improvement, Credentialing, Health Risk Assessment departments.
- Led successful NCQA certifications for Health Risk Assessment, Credentialing, and Case Management; Joint Commission recertification for Home Health, and Patient-Centered Medical Home (PCMH) certifications for multiple health plans.
- Implemented the CMS Model of Care for the Special Needs Plan (SNP) Case Management program across multiple health plans.
- Spearheaded implementation and evaluation of the Cultural Competency Program and ADA Compliance Program across FL, IL, NY, and VA, ensuring adherence to all applicable state requirements.
- Chaired the Quality Improvement Committee and Credentialing Committee, in coordination with the Chief Medical Officer/Medical Director; provided quarterly reports to the Board of Directors.
- Developed and executed Performance Improvement Plans (PIPs) in compliance with state, federal, and internal standards to drive organizational excellence.
- Launched and maintained oversight of Long-Term Care Program activities, aligning with CMS expectations and member needs.
DIRECTOR, QUALITY IMPROVEMENT/CASE MANAGEMENT
Florida Healthcare Plus
01.2013 - 01.2014
- Direct reporting to COO and CEO with operational oversight activities for Quality, Case Management, Risk Adjustment, Health Risk Assessment/ Utilization Management departments
- Built the Quality Improvement Department along with the implementation of policies/procedure, programs, and work plans for the organization.
- Spearheaded the Quality Improvement Committee and reported to the Board of Directors
- Executed the Consumer Assessment for Health Plan (CAHPS) Survey, Health Outcome Survey, Member Satisfaction Survey and Provider Satisfaction Survey, post evaluation of survey results for the identification of areas for improvement.
- Initiated and executed the Health Effectiveness Data and Information Set (HEDIS) Project; contracted with certified HEDIS vendors and actively participated during the onsite audits; reporting HEDIS results to the National Committee for Quality Assurance (NCQA).
- Oversight and review of the Member Newsletter and member material prior to CMS approval.
- Directed the Health Risk Appraisal Unit, ongoing oversight of staff performance.
- Directed the accreditation of the Health Plan by the Accreditation Association for Ambulatory Healthcare (AAAHC)
- Spearheaded the 5 Star Program and ongoing initiatives.
DIRECTOR, QUALITY IMPROVEMENT
Preferred Care Partners/Care Florida (United Healthcare Group)
01.2003 - 01.2013
- Develop, implement and manage the organization’s Quality Improvement Program, including policies and procedures.
- Oversee regulatory compliance and quality accreditation efforts, including those related to URAC, CMS, NCQA, and state health departments.
- Monitor and reported on key quality metrics, including patient safety indicators (i.e. HAC, SRAE), CAHPS, HOS, etc.
- Medicaid specialist for the Care Florida Medicaid product and ample knowledge of the Children’s Health Insurance Program.
- Responsible for supervising and overseeing the Department’s staff as well as assisting in the daily operations, budget and directing quarterly company-wide quality committee meetings.
- Partner with other operational departments to lead evidence-based initiatives aimed at improving quality of care and member experience.
- Implementation, evaluation and submission of Chronic Care Improvement Programs (CCIP) and Quality Improvement Program (QIP).
- Developed programs including efforts to reduce readmission, chronic health conditions and diabetic management.
- Oversee provider audits, internal departmental audits and delegate activity through the Quality Improvement Committee and address Corrective Action Plans to improve the overall quality of care.
- Led initiatives to improve STAR rating, managed quality metrics, and analyzed performance data.
- Educate and mentor staff on QI and regulatory compliance and act as a clinical liaison to other departments within the organization.
Education
Bachelor of Science in Nursing -
University of Miami School of Nursing
Coral Gables, FL01.1992
Skills
- Quality Improvement
- NCQA, AAAHC, URAC Accreditation
- Regulatory CMS Audits
- HEDIS & STAR Ratings
- Relationship Building & Team Collaboration
- Case Management
- D-SNP / C-SNP Model of Care
- Utilization Management
- Regulatory Compliance and reporting
- Data Analysis and Clinical Review
- Personal and Professional Integrity
- Policy & Procedures Development
- Program Development & Operationalization
- Proficient in the use of multiple software systems: FACETS- (TriZetto), Care Prominence (MedHOK), Invidasys, EMRs (Epic), Cotiviti
- Decision-making
- Team leadership
- Critical thinking
Accomplishments
Achieved significant increase in STAR rating measures over 2 years.
Developed and led the eCare RPM Program achieving $600K ROI in year one by reducing hospital readmission rate.
Certification
- Critical Care Nurse (CCRN) Certification
- Six Sigma Green Belt
Languages
Fluent in English and Spanish (written and spoken)
Timeline
VICE PRESIDENT OF HEALTH SERVICES & QUALITY IMPROVEMENT
Clear Spring Health
01.2017 - Current
VICE PRESIDENT QUALITY IMPROVEMENT
Independent Living Systems (ILS)
01.2014 - 01.2017
DIRECTOR, QUALITY IMPROVEMENT/CASE MANAGEMENT
Florida Healthcare Plus
01.2013 - 01.2014
DIRECTOR, QUALITY IMPROVEMENT
Preferred Care Partners/Care Florida (United Healthcare Group)
01.2003 - 01.2013
Bachelor of Science in Nursing -
University of Miami School of Nursing
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