Bethany McDermott

• Oversight of NCQA Health Plan accreditation work for 11 Prepaid Health Plans, serves at NC Medicaid NCQA accreditation subject matter expert
• Leads oversight of Health Plan Accreditation (HPA) and Health Equity Accreditation for five managed care Prepaid Health Plans (PHP)
• Leads oversight of Health Plan Accreditation with LTSS Distinction for six Local Management Entity-Managed Care Organizations (LME-MCOs)
• Direct annual program improvements in response to program trends and program goals, in collaboration with advisory boards, health plans (PHPs/PCCM), and internal stakeholders
• Maintain and update all contractual requirements for quality management and improvement for PHPs, PCCMs, and LME-MCOs
• Oversee Quality Management and Improvement programs for each PHP, LME-MCO, and PCCM
• Oversee annual review/approval of program plans, Quality Assessment and Performance Improvement (QAPI) plans, and performance improvement projects (PIPs)
• Directs External Quality Review activities for all PHPs and PCCM programs
• Directly oversee SOW development and vendor performance
• Oversees annual EQRO validations and report creation
• Review and assess inbound deliverables required of the Standard Plans, Tailored Plans (LME-MCOs/PIHPs), and Eastern Band of Cherokee Indians (EBCI-Tribal Option)
• Recruits, selects, and manages ten employees including delegating to support staff, encouraging professional development and growth, and fostering professional development
• Engages and collaborates with Division of Mental Health, Developmental Disabilities and Substance Abuse Services Customer Service and community Rights team on critical incident reporting and management, including drafting support on Request for Proposal for new critical incident reporting platform

Accomplishments

• Successfully launched six Prepaid Inpatient Health Plans (PIHP) on April 1, 2023
• Successfully executed five contract amendments totaling approximately $23M in 2023.

• Oversight and direction to Pre-Paid Health Plans, monitoring quality management and improvement interventions, processes, and policies aimed at increasing health outcomes for approximately 2.9 million North Carolina Medicaid beneficiaries
• Facilitated the MCAC Quality Management subcommittee which included managing agendas and quarterly meetings, managing report-outs to the MCAC committee and participants, and cultivating and strengthening relationships with 11 committee members and two co-chairs representing providers and beneficiaries from communities across North Carolina
• Maintained the MCAC Quality Management subcommittee webpage
• Engaged Division of Health Benefits leadership and other stakeholders through presentations and forums around quality improvement initiatives and maintains relationships with Quality Directors of Health Plans
• Managed annual updates to the Quality Strategy, including public posting, presentation to internal and external governance committees, review by EQR vendor and approval by CMS
• Led the quality scope of work for the $15M NC Area health Education Center (AHEC) contract, including provider support and transformation programs as well as supervision of employees
• Accomplishments
• Division of Health Benefits liaison for Keeping Kids Well campaign, partnering with Pfizer, (AHEC) and Community Care of North Carolina (CCNC) to perform outreach to pediatric provider practices with more than 500 open care gaps
• Approximately 58,000 postcards were distributed between December 2020-August 2021, improving rate of Childhood Immunization Status Combo 10 to pre-pandemic rate
• Successful launch of $6B Medicaid Managed Care program on July 1, 2021

• Analyzed financial comparison based on vendors financial stability and risk exposure
• Procured vendor search criteria for inclusion in detailed information gathering and review of initial vendors identified to determine scoping parameters and awarded $3M contract for In-Home Assessment program
• Designed Quality Improvement Management Workplan to enhance content and ensure language simplification
• Reviewed member facing materials according to National Committee on Quality Assurance (NCQA) standards
• Facilitated quarterly Quality Improvement Committee meetings with internal stakeholders to ensure continued compliance with NCQA accreditation for Medicare and Commercial lines of business
• Prioritized Center for Medicare and Medicaid Services (CMS) Health Plan Management System (HPMS) memos to distribute to relevant team members
• Facilitated departmental and committee meetings, prepare necessary presentation material, document and follow-up on important actions and decisions

Accomplishments

• Elected as Employee Network Board Member, asked to be Co-Chair effective 6/2019
• Participated in Leadership Development Program, developed Capstone Project to increase membership in Employee Networks across Enterprise by 15% in 12 months

• Evaluated quality assurance of departmental operational activities to determine the effectiveness of internal compliance procedures, soft skills, and accurate resolution
• Identified and reported call trends, discrepancies and facilitated call calibration sessions with leadership to ensure performance metrics were established to enhance the member’s experience
• Coached and monitored the progress of 23 customer service representatives and provided written, face-to-face coaching and feedback regarding quality audit results to improve individual and team
• Performance, including identifying audits requiring investigation
• Presented at team meetings to keep teams abreast of audit trends, strengths, and areas of improvement
• Participated in the Blue Exchange program as a Mentee
• Completion of Lean 101 Training

Accomplishments

Participated in Process Improvement workgroup, my calibration initiative reduced meetings by 65% over 12 months

• Engaged customers about concerns and questions regarding their benefit, eligibility, billing and claims inquiries and encouraged customers to utilize alternative channels such as self-service and web-service platforms
• Identified and communicated process, product, and system improvement opportunities to improve the overall stakeholder experience
• Partnered with local, state, and federal governmental entities regarding Blue Cross North Carolina products, services, and policies
• Worked collaboratively with internal and external departments such as Sales, Healthcare, Network Management and The Federal Insurance Marketplace to further optimize customer, employer group and provider relations by identifying opportunities to promote stakeholder programs and effectively and efficiently resolve customer issues
• Recognized patterns of inconsistent and/or inaccurate claims filing practices among customers and providers, educated customers and providers on acceptable Blue Cross North Carolina practices and policies