Tiffani Hilton

• Under direction of Vice President of Clinical Process Improvement responsibilities include collaborating with Care Management and Behavioral Health Medical Directors and Vice Presidents to develop and implement strategies, and controls which identify adherence and non-adherence to Compliance and Regulatory requirements, HEDISI, STAR and MLTC quality measures; and Key Performance Indicators (KPIs) for clinical departments, vendors, member and provider facing programs.
• Oversee large cross-functional portfolio of projects to support clinical and non-clinical teams transition from reactive model of care to proactive approach to disease management which include developing pathways to address Social Determinants of Health.
• Confer and collaborate with clinical, quality, IT and Enterprise Analytics departments to develop process improvement models, define and monitor performance/operational reporting and metrics.
• .Define project scope, manage and monitor timelines and milestone dates, document and report barriers and bottlenecks impacting project success; coordinate with business leaders to develop remediation plans.
• Develop project charters and manage project scope, standardizing process flows and reporting methodologies to guide projects from conceptualization to implementation and maintenance.
• Monitor contracts and service level agreements to identify potential risks and implement mitigation actions to protect development process from unforeseen delays and costs.
• Gather project requirements through interactions, meetings and walk-throughs with potential application users to develop business requirements documents (BRD), functional requirements documents (FRD) and user mockups.
• Collaborate with business users, technical teams, database administrators and testing teams during kickoff meetings, joint application designing and planning sessions to validate requirements.
• Managed and led multi-disciplinary design team throughout development and launch of 2021 Q4 Quality Push to potential yield $30 million from Quality withhold.
• Partner with management to identify end user education and training needs/requirements. Ensure controls are in place to monitor adherence to polices and procedures. Adjusted project plans to account for dynamic targets, staffing changes and operational specifications.
• Serve as subject matter expert for report development and systems integration, performance improvement design strategy.
• Worked with external vendors to streamline workflows and reporting methodologies to align with parent company and peer venders.

Accomplishments

• Initiated Medicare Stars Q4 Interdepartmental Strategic Push
• Identified process and technical gaps impacting plan's ability identify key barriers to closing quality gaps.

• Reported to AVP of Clinical Regulatory Compliance responsible for developing strategic monitoring plans, operational goals/objectives and controls to provide continuous clinical and non-clinical oversight of Special Needs Programs (SNP) Model of Care (MOC).
• Developed concurrent and retrospective reporting/audits to proactively identify areas of non-compliance.
• Revised and initiated workflows and controls aimed at increasing transparency, continuous improvement, risk mitigation and foremost adherence to state/federal and contractual requirements.
• Used of STAR and HEDIS measures/outcomes to identify opportunities to increase member/provider engagement, improve health conditions, risk stratification and overall member/provider satisfaction.
• Met with internal and external business partners and vendors responsible for providing direct and indirect member care to review oversight plan, audit findings/results and remediation of corrective action plans.
• Supervised and directed Registered Nurses, Licensed Social Workers, Business Analysts and Quality Assurance team to develop controls aimed at increasing transparency and improving outcomes.

Accomplishments:

• Passed CMS 2021 audit, becoming best practice model for other plans.
• Developed oversight plan according to CMS Model of Care guidelines to monitor key aspects of end to end processes and adherence to Compliance/ Regulatory requirements.
• Collaborated with clinical management and front line staff, created audit process, tools and controls used to monitor and measure compliance.
• Together with IT Application Develop, Informatics and Clinical Analytic teams developed reporting to proactively identify triggers/indicators of process gaps, non-compliance; tracked and trended key performance indicators (KPIs) and criteria identified as critical to quality (CTQ).

• Worked in conjunction with organizations’ CEO, CFO and Vice President to restructure organization’s strategy; resulting in establishing POL as prominent educational resource for bone marrow and cord blood banking, particularly for ethnic individuals.
• Strategically planned and oversaw all aspects of operations and project management including; introduction of legislation in New York State, bone marrow donor drives, cord blood banking program at major New York City hospital, community outreach, health fairs and initiation of marketing campaigns (viral, print and radio).
• Spoke publicly on behalf of organization to legislative bodies, television and radio audiences; moderated symposiums and appeared on various panel discussions. developed action plans to respond to audit discoveries and compliance violations.
• Liaised with risk management, internal audit and employee services departments to direct compliance issues to appropriate channels for investigation and resolution.
• Implemented improvement initiatives and developed compliance testing program to monitor and identify gaps in new and existing practices.
• Identified potential areas of compliance vulnerability and risk to develop and implement corrective action plans.
• Focused teams on developing innovative and cutting-edge approaches with effective resource allocation and strategic planning.
• Offered expertise on employee and business development plans to enhance implementation and routine oversight.

Accomplishments:

Launched New York City Health and Hospital Corporation's first public cord blood banking program.

• Managed team of Business Analysts, Performance Improvement Analysts and Commission Analysts who provided analytic and organizational support to Sales, Marketing, Product Management, Intake/Enrollment, Care Management and Reassessment for all integrated product lines of business.
• Lead team of 8 Business Analyst responsible for overseeing adherence to QA/regression testing schedule; working collaboratively with internal departments, stakeholders and various teams of consultants in IT and Risk Management to develop new applications/ platforms aimed at streamlining business practices to enhance member/provider experience aimed at increasing membership and revenue.
• Developed policies and procedures; identify measures critical to quality (CTQ) in support of new business initiatives.
• Managed large-scale implementations on platforms such as Salesforce and Provider Portal. .
• Created controls to manage critical aspects of broker/member credentialing; enrollment and renewal processes. Developed standardized reporting; improved report request processes, timely fulfillment of requests received and overall completion time.

Accomplishments:

• Onboarded, trained and developed Commission Analysts; led and developed Business Analysts supporting launch of plan's commercial line of business.
• Strategized with internal business owners to develop policies/procedures, created training manuals, process maps, control plans specific to onboarding and credentialing external brokers, agents and internal captive agents supporting organizational growth and continuous process improvements leading to launch of plan’s commercial line of business.

• Managed three units: Business Analysts, Interactive Quality Assurance and Quality Performance Improvement Auditors provided business analytic support, auditing and performance/ process improvement oversight for Intake & Enrollment (field and call center staff) and Care Management departments.
• Strategized with leadership to develop best practices, key performance indicators (KPI’s), various oversight processes and tools used to enhance transparency, proactively manage, track and report adherence to internal and external requirements.
• Developed annual account objectives and formalized client communications for communication of goals and plans.
• Consulted with managers and people leaders on change management strategies and best methods to engage high functioning employees and enhance work completed by low performing staff.
• Responsible for development, implementation and management of Senior Health Partners’ annual audit plan including audits and validation of business units results.
• Responsible for determining criteria used to develop corporate grading system used as benchmark to monitor delegated partners against organization’s MLTC quality standards.
• Collaborated with Legal, Compliance, Regulatory, Finance, Care Management and Intake/Enrollment in preparation for and in response to audits conducted by government agencies and hired consultants.
• Managed, trained and mentored clinical and non-clinical staff in house and remotely with use of Go To Meeting and other interactive technologies.

Accomplishments:

• Collaborated with Performance Improvement to launch plan’s first Lean Six Sigma White Belt training program.
• Led multi-departmental team which identified root cause of disenrollment non-compliance, develop enhanced workflow processes and controls proactively identifying when to act. These efforts resulted in creation of disenrollment teams and promotion of internal staff member to team manager.
• Conducted pre-delegated oversight for three partnerships, two simultaneously resulting in timely launch while leading staff during period of reorganization.
• Developed bi-annual audit criteria and trained Account Managers on oversight protocols.

• Reported to Vice President of Clinical Excellence collected clinical outcome data, key performance metrics, performed analysis in support of clinical process improvement initiatives and facilitated review of program effectiveness.

Accomplishments:

• Developed oversight metrics and presentations for senior leadership and quarterly Quality Utilization, Quality Management and Delegate Oversight Committee meetings.

• Initiated and reviewed Compliance and contractual Key Performance Indicators (KPI) with organization’s COO and President.
• Delivered subject matter expertise for internal and external customers on compliance best practices and quality control.
• Created Plan of Action establishing new policies, procedures and duties for internal staff (where needed) resulting in successful passing of Broadlane; Health and Hospital Corporation (HHC) audit.
• Directed all internal and external audits; led and conducted completion of file review; confirmed background checks, online verifications and credentials had been received for current and potential staff in accordance with contractual and Joint Commission guidelines which included, foreign doctors, nurses, allied, clinical and non-clinical employees.
• Created and submitted performance based reviews for temporary staff. Initiated and maintained credentialing report of all staff. Drafted and ensured compliance letters were disbursed advising employees of annual recertification required in order to avoid non-compliance and maintain employment.
• Managed compliance efforts, reporting and audits.

• Managed IPRO (facility) independent appeal process.

• Completed administrative duties to support timely appeal review.

• Processed Medicaid and Medicare grievance and appeal request for members, providers and facilities.

• Created professional and error-free business correspondence to communicate with prospective and currently enrolled participants.

• Maintained customer satisfaction with forward-thinking strategies focused on addressing customer needs and resolving concerns.