Debra K. Jacobs
Cape Coral
Summary
Managed Care Operations Expert. Executive strategic and visionary clinical leader recognized in the industry for innovative oversight of public and private major healthcare organizations. Development of high performing teams who meet and exceed all expectations related to productivity, best practice A/I and operational effectiveness. Clinical and regulatory expert in all products for Medical and Behavioral Health Services under all products, Medicare, Medicaid, D-SNP, LTSS, CHIP and Commercial. Achievements include 25 years of impactful operational experience, building integrated delivery models with behavioral health, population health and care management, STARS and HEDIS road map and oversight. Quality program oversight, aligning utilization management with care management services, development of accountable care models, long term and subacute network alignment and building dedicated concierge team models. NCQA< CMS and URAC subject matter expert. Leads organizational change management support and education. Oversight of client services, claims team, clinical intake operations teams and call centers. Demonstrated success in establishing aligned diverse teams to develop care pathways that effectively provide patient services throughout the continuum of care. Aligned cross regional and national teams in complex matrixed organizations, building standardized platforms. A seasoned leader with strong emotional intelligence and change management skills. Lead a startup project for community health choices program (DSNP) from start to implantation for multi-regional footprint expansion for a major Health plan. Oversight to extensive P/L and over 500 nationally positioned FTEs in multi-site/state organizations. Managing complex departments at Health Plan organizations with over 3, million members and multi plan product portfolio. In all roles have a positive record of impactful leadership in engaging successful, high performing teams, process improvement standards that meet and exceeds business objectives, and government regulatory requirements, cost containment, supporting growth and expansion of organizational footprint…
Overview
30
30
years of professional experience
Work History
Sentara Health Plan
05.2024 - Current
- Major organizational restructure
- UM Wave Projects coverage 9 critical key deliverable projects with a cost reduction impact of over 25 million the first year planned for 2025 go live
Vice President of Utilization Management (UM) and Medical Policy
Boston Medical Health Plan – Wellsense
05.2021 - 08.2023
- Reports to CNO, and SVP, 150 FTEs, 2 major budget cost centers Utilization Management, Behavioral Health, Clinical Intake Operations, and Medical Policy
- Alignment of claims configuration activity and payment integrity efforts for medical, behavioral health and pharmacy
- Built infrastructure to successfully launch and onboard 300 new ACO members
- Lead for Mental Health Parity oversight
- Development of ACO Model with a concierge approach and gold carding unique to the industry
- Develop system and enterprise best practice utilization engagement strategies to support a solid infrastructure for advancement as an integrated finance delivery system
- Integration of UM, CM and behavioral health model through weekly collaborative rounds and alignment of cost saving strategy efforts
- Implemented system automation and extensive vendor integration efforts
- Launch of a subspecialty vendor for Radiology, Genetic Testing and Musculoskeletal
- Aligned all affordability initiatives and reported impact to organization’s financial targets
- Monitored overall Utilization of Care Trends in medical, behavioral and pharmacy services while identifying cost and savings opportunities
- Developed and maintained priorities of all enterprise clinical programs, projects and pilots
- Led and participated in new business development activities and proposals
- Engaged in pre-proposal strategic activities, proposal reviews, proposal writing, and project start-up activities
- Collaborated with program/project initiative developers, business owners, business sponsors and other stakeholders to ensure inputs, processes, and outputs are captured and maintained for effective implementation
- Revamp and re-write of all Medical Policies, Oversight and chair of Clinical Oversight and medical policy committee, key executive who oversees all regulatory activity related to utilization management, behavioral health and Medical Policy
- Successfully aligned integrated delivery teams dedicated to BMC facilities
- Key role in the launch of NH Medicare Advantage
- Implemented a subspecialty vendor with a collaborative care approach to reduce medical cost trends
Assistant Vice President Clinical Operations
UPMC Health Plan
09.2016 - 02.2021
- Company Overview: UPMC is an integrated delivery finance system with over 70,000 employees and 3 million members, all lines of product business including Commercial, Medicare, and Medicaid products including, Behavioral Health and Community Health Choices
- Reports to CNO, and SVP of Network, 350 FTEs, 3 major budget cost centers Utilization Management, Clinical Intake Operations, and Complaints and Grievances
- Develop system and enterprise best practice utilization engagement strategies to support a solid infrastructure for advancement as an integrated finance delivery system
- Key executive who oversees all regulatory activity related to behavioral health, utilization management, complaints and grievances, and clinical operations
- Successfully aligned integrated delivery teams dedicated to UPMC facilities, Oversight of Clinical Operations/Client Services Teams, key role in the launch of Community Choice Programs/DSNP and launch of new JV program
- Implemented a subspecialty vendor with a collaborative care approach to reduce medical cost trends – saving 2 million/month
- Established a collaborative care model approach for utilization services recognizing cost savings of over 2 million/month
- Aligned integrated delivery teams for payer owned organizations
- Built a value-based payment program for a vulnerable pediatric population
- UPMC is an integrated delivery finance system with over 70,000 employees and 3 million members, all lines of product business including Commercial, Medicare, and Medicaid products including, Behavioral Health and Community Health Choices
Vice President of Health Services
Mount Carmel – MediGold
12.2014 - 09.2016
- Reports to CEO, 150 FTEs, 3 major budget cost centers Departments; Utilization Management, Quality and Pop Health
- Established and rebuilt infrastructure for three key areas of oversight: Quality, Behavioral Health, Utilization Management, and Population Health, Care Management/Wellness coaches
- Alignment and integration with Population Health, Behavioral Health and Wellness teams
- Effectively mediated system conversion impact for the three departments and reestablished compliance priorities for the specific areas noted
- Established value-based outcome reporting and oversight model for providers
- Oversight of STAR/HEDIS strategic planning and outcomes with a 4.5 performance rating
- Successful CMS audit after nine years
- Partner with Long term care providers to launch a dedicated sub-acute collaborative approach
- Client and Provider Management
- System Upgrades and launch of new platform
Director of Care Management
Molina Healthcare (Interim)
02.2014 - 12.2014
- Reports to Vice President of Health Services, over 300,000 membership – 5 direct reports and over 150 indirect FTE reports
- Budget cost center for Cincinnati and Dayton markets
- Directed all launch activity for a new product line for over 10,000 Medicare/Medicaid members/DSNP
- Established a new office start-up program hiring/training over 150 staff
- Developed policies and job aides creating a blueprint for operational processes compliant with the new Ohio MMP (Medicare/Medicaid dual demonstration program)
- Maintained budget and staffing model for new start-up program
- Hosted provider education and member education events
- Oversight of quality functions including HEDIS measures and NCQA compliance and all areas of regulatory reporting and activity
Vice President of Clinical and Client Services
MEDLAB
10.2010 - 12.2013
- Reports to COO, Board Member, Oversight of call /dispatch center and Client Management Team as well as Leadership of over 500 phlebotomy staff, 25 locations/supervisors, two quality managers, and one corporate trainer
- Consultative Client Management – Oversight of Client Services Team
- Oversight of Customer/Client Dispatch Unit
- Established the corporate blueprint for phlebotomy services and aligned all standard operating procedures servicing 1,500 nursing facilities in seven states, including PSC sites new and established labs
- Successful CLIA and CAP audits
- Implemented paperless system for call center/dispatch unit
- Lead organizational change management and implemented the 7 C’s launch of a new culture for the organization
- Worked with Client team on root cause analysis for any quality issues
Humana Regional Clinical Process Manager
Humana Inc.
03.2008 - 10.2010
- Reports to Regional Director of the Clinical Guidance Organization (CGO) regional process manager for the Lexington, Virginia, and Ohio markets’ population of over 300,000 members
- Responsible for oversight of utilization and case management clinical operations in Ohio
- Lead project team to convert to Milliman Guidelines – with a resulting 2% overall cost savings in inpatient utilization
- Lead project team to implement an impactful transition of care model that is still in place
- Client Solutions and Account Management SME
Clinical Regional Manager / Director Regional
Sedgwick CMS (Merged with Comp Management Health -Systems/Anthem Managed Comp)
03.1998 - 01.2008
- Reported to the VP of Healthcare operations
- Responsible for Virginia, DC, Pennsylvania, North Carolina, and Ohio clinical operations with a department of over 300 staff
- NCQA and URAC accreditation oversight
- Key contact for high profile clients
- Set up a pilot for proactive care resulting in a reduction in employer cost of 2.5 percent
Regional Manager
Aetna/US Health Care
12.1994 - 10.1997
- Direct leadership of 30 clinical nurses and 10 support staff and membership of over 150,000
- Developed disease case management program
- Implemented successful fax precertification program
- Successful UPRAC accreditation
- Claims, Appeals and grievance, Call center operations, Disease Management, Care Management, Behavioral Health, and all related operations
- Established ERIN Program – Early Risk Intervention Network with a cost savings of over 1.5 million a year for the senior population
- Played a key role in system conversion and testing
- Initiated cost saving measures through case management process
- Member of the Quality Improvement Committee
Education
Certified Rehabilitation Nurse -
02.2025
MSN Program - Hospital Systems Administration
Excelsior College
01.2011
Bachelor of Science Degree -
Excelsior College
01.2009
Registered Nurse — Associate Science of Nursing -
01.1992
Skills
Enterprise in areas of aligning processes and improving compliance and KPIs
Education And Certification
MBA, Nursing Leadership, Excelsior College, 2016 - Present, MSN Program, Hospital Systems Administration, Excelsior College, 2011, Bachelor of Science Degree, Excelsior College, 2009, Registered Nurse, Associate Science of Nursing, 1992, Certified Rehabilitation Nurse, 2006 - Current, Legal Nurse Consultant - LNC
Top Talents
- Managed Care Operations Expert
- Executive strategic and visionary clinical leader recognized in the industry for innovative oversight of public and private major healthcare organizations
- Development of high performing teams who meet and exceed all expectations related to productivity, best practice A/I and operational effectiveness
- Clinical and regulatory expert in all products for Medical and Behavioral Health Services under all products, Medicare, Medicaid, D-SNP, LTSS, CHIP and Commercial
- Achievements include 25 years of impactful operational experience, building integrated delivery models with behavioral health, population health and care management, STARS and HEDIS road map and oversight
- Quality program oversight, aligning utilization management with care management services, development of accountable care models, long term and subacute network alignment and building dedicated concierge team models
- NCQA, CMS and URAC subject matter expert
- Leads organizational change management support and education
- Oversight of client services, claims team, clinical intake operations teams and call centers
- Demonstrated success in establishing aligned diverse teams to develop care pathways that effectively provide patient services throughout the continuum of care
- Aligned cross regional and national teams in complex matrixed organizations, building standardized platforms
- A seasoned leader with strong emotional intelligence and change management skills
- Lead a startup project for community health choices program (DSNP) from start to implantation for multi-regional footprint expansion for a major Health plan
- Oversight to extensive P/L and over 500 nationally positioned FTEs in multi-site/state organizations
- Managing complex departments at Health Plan organizations with over 3 million members and multi plan product portfolio
- In all roles have a positive record of impactful leadership in engaging successful, high performing teams, process improvement standards that meet and exceeds business objectives, and government regulatory requirements, cost containment, supporting growth and expansion of organizational footprint
Timeline
Sentara Health Plan
05.2024 - Current
Vice President of Utilization Management (UM) and Medical Policy
Boston Medical Health Plan – Wellsense
05.2021 - 08.2023
Assistant Vice President Clinical Operations
UPMC Health Plan
09.2016 - 02.2021
Vice President of Health Services
Mount Carmel – MediGold
12.2014 - 09.2016
Director of Care Management
Molina Healthcare (Interim)
02.2014 - 12.2014
Vice President of Clinical and Client Services
MEDLAB
10.2010 - 12.2013
Humana Regional Clinical Process Manager
Humana Inc.
03.2008 - 10.2010
Clinical Regional Manager / Director Regional
Sedgwick CMS (Merged with Comp Management Health -Systems/Anthem Managed Comp)
03.1998 - 01.2008
Regional Manager
Aetna/US Health Care
12.1994 - 10.1997
Certified Rehabilitation Nurse -
MSN Program - Hospital Systems Administration
Excelsior College
Bachelor of Science Degree -
Excelsior College
Registered Nurse — Associate Science of Nursing -
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