Doris Louissaint
Valley Stream,NY
Summary
Healthcare professional with project development, implementation, and oversight skills. I have worked with Medicaid and Medicare managed care for more than 15 years with substantial knowledge and experience working with Medicaid and Medicare managed care organizations (MCOs) and state and federal regulatory staff. I have extensive experience with all mandatory and optional Medicaid managed care external quality review (EQR) regulations and mandatory and optional EQR tasks including medical record review, quality improvement, regulatory compliance reviews, performance measures, data validation and special projects, preparation of EQR technical reports, and providing education, support, and technical assistance to MCO staff and federal customers.
Overview
12
12
years of professional experience
Work History
Medical Officer, Managed Care
IPRO
01.2024 - Current
- Manage, design, and implement performance improvement projects and clinical focus studies
- Serve as managed care performance improvement liaison between IPRO and state clients
- Participate in data analysis to assess patterns of care or outcomes, including the development, implementation, and evaluation of performance measures
- Assist multi-disciplinary team in using clinical information and interpreting clinical findings related to focused studies, performance improvement projects, compliance reviews and measure validations
- Write reports for Medicaid agencies, MCPs, providers, consumers and CMS that explain findings from performance improvement projects and focused studies and make programmatic recommendations
- Train IPRO and managed care plan staff and others in QI principles, intervention design and implementation, and other clinical topics
- Assist in the interpretation of HEDIS and other performance measure specifications and provide clinical input into the HEDIS/performance measure audit/validation process including medical record review validation
Senior Clinical Transformation Manager, Managed Care
United Healthcare
01.2022 - 01.2023
- Develop strategies based on performance analysis for improvement that include specific outcomes and metrics to monitor progress
- Design practice transformation action plans and implement appropriate performance improvement initiatives designed to assist the practice in achieving contractually required transformation milestones
- Use data to analyze trends and work with stakeholders to agree on and implement proactive strategies to address issues and measure impact
- Assist practices in creating workflows to optimize care delivery
- Consult and guide the practice on developing innovative solutions
- Work with practice to align and integrate disease management programs and population health services to augment the practice’s capabilities
Practice Performance Manager, Managed Care
United Healthcare
01.2018 - 01.2022
- Executed applicable provider incentive programs for health plan
- Developed comprehensive, provider-specific plans to increase their HEDIS performance and improve their outcomes
- Provided ongoing strategic recommendations, training and coaching to provider groups on program implementation and barrier resolution
- Lead on STARS specific JOC meetings with provider groups with regular frequency to drive continual process improvement and achieve goals
- Performed risk adjustment coding
Clinical Quality Analyst, Managed Care
United Healthcare
01.2013 - 01.2018
- Executed analysis and review of quality outcomes at the provider level
- Monitoring and reporting on key measures to ensure providers meet quality standards and implementation of pay for performance initiatives
- Education of provider and office staff regarding billing and encounter submission in accordance with health plan regulatory requirements
- Support of plan and regulatory-required quality initiatives
- Hybrid Medical Record retrieval as necessary
Education
Medical Doctor -
Belize Medical College
01.2008
Bachelor of Arts - Psychology
St. John’s University
Jamaica, NY01.2000
Skills
- Direct patient care
- Patient health education
- Provider education
- Healthcare management
- Chronic disease management
Affiliations
- Candice’s Sickle Cell Fund, Inc., Board of Directors, 01/01/08 - Present
- Alpha Kappa Alpha Sorority, Inc., Member, 01/01/02 - Present
Timeline
Medical Officer, Managed Care
IPRO
01.2024 - Current
Senior Clinical Transformation Manager, Managed Care
United Healthcare
01.2022 - 01.2023
Practice Performance Manager, Managed Care
United Healthcare
01.2018 - 01.2022
Clinical Quality Analyst, Managed Care
United Healthcare
01.2013 - 01.2018
Bachelor of Arts - Psychology
St. John’s University
Medical Doctor -
Belize Medical College
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