Jaime McDonald

Oversight over newly consolidated clinical care management department including Medicaid and Medicare products.

Accomplishments:

• Streamlined care management processes throughout all product lines (MLTC, Medicare, HIV Special Needs Plan) increasing operational efficiencies by 10%
• Clinical oversight of SelectHealth- HIV Special Needs Plan (SNP)'s migration to a new care management platform with increased clinical insights, updated assessment tools, operational efficiencies, and increased access to outcome reporting by 50%
• Transition of new employee training for SelectHealth care management staff to the Education Department reducing training and onboarding time by 20%; ongoing collaboration with Education Department to identify additional training needs for new and existing employees, assisting with the development and delivery of training as needed
• Collaboration with the Quality Department to set care management quality goals (HEDIS, CAHPS, HOS, QARR, and HIV Quality of Care Program), establishing and monitoring key performance indicators
• Collaboration Utilization Management, Compliance, Provider Relations, Claims Integrity, and Business Analytics to complete and revise the NYS Mental Health Parity and Addiction Equity Act (MHPAEA) Medicaid Managed Care NQTL Reporting
• Subject matter expert for HIV SNP authorizations and utilization management post-transition to dedicated Utilization Management and Service Operations departments

Clinical oversight of NYS Medicaid HIV Special Needs Plan (SNP) care and utilization management program.

Accomplishments:

• Development and implementation of policies & procedures in alignment with NYSDOH requirements
• Implementation of data-driven operational efficiencies to improve the end-to-end process service authorization request receipt to notification of determination process, improving turnaround times by 20% and increasing compliance with NYSDOH requirements
• Promotion of evidenced-based clinical pathways to address health concerns of special needs populations (HIV+, transgender, homeless individuals, and their dependents) and contributing to the health plan's 82% viral load suppression rate in coordination with the health plan's End the Epidemic (ETE) grant-funded program
• Participation in Article 44 full program and targeted audits resulting in either none or minimal findings or recommendations in care or utilization management
• Implementation of changes to the HIV SNP eligibility and benefits package as directed by NYSDOH (changes to eligible populations and/or covered benefits)
• Participation in presentations to the community and stakeholders to increase public awareness and improve public perception of the plan to support growth and sustainability (provider groups, community-based organizations, AIDS Walk, NYC Pride March/PrideFest)

Oversight of care management operations for Fully Integrated Duals Advantage (FIDA) and Medicare product lines.

Accomplishments:

• Collaborate with clinical and product leadership to develop and implement care management goals and objectives aligned with strategic organizational objectives and financial targets
• Develop, revise, and implement policies and procedures in alignment with CMS and NYSDOH regulatory requirements
• Collaborate with Utilization Management counterparts to develop and implement workflows promoting timely determinations, supporting care coordination, discharging planning, and transitions of care
• Oversight of care management platform customizations and upgrades to improve productivity and regulatory compliance with care planning documentation by 15%
• Develop, implement, and monitor corrective action plans based on internal audit findings.
• Management of 35-40 clinicians (Registered Nurses and Licensed Social Workers)

Management of care management team.

Accomplishments:

• Oversight of up to 15 clinicians (Registered Nurses and Licensed Social Workers) in care and utilization activities
• Developed annual departmental goals and completed performance appraisal; when appropriate developed and monitored performance improvement plans for clinicians requiring remediation
• Educated staff on CMS and NYSDOH regulations governing managing care organizations and evidenced-based care management practices
• Collaborated with various internal stakeholders to resolve member concerns, vendor issues, and provider concerns, and improve gaps in internal processes
• Investigated and provided information to Grievance and Appeals, Compliance, and Quality departments
• Compiled data and submit quarterly and annual reports to CMS and NYSDOH.

Clinical lead for a team of 15 clinicians (Registered Nurses and Licensed Social Workers) responsible for providing telephonic care management (average caseload of 100 members each)

Achievements:

• Audited care management records to ensure quality of care coordination, fiscal responsibility in the provision of covered benefits, and monthly contact standards were met consistently
• Maintained staff morale and employee retention through effective communication, prompt problem resolution, proactive supervisory practices, and encouraging a proactive work environment
• Assisted Staff Educator in training new employees
• Participated in readiness activities for the FIDA demonstration including developing care management protocols and end-user testing for required system upgrades.

Team leader and office-based clinical resource for a field-based team of 10-15 Registered Nurses

Accomplishments:

• Oversight and coordination of field-based nursing team's activities to ensure availability of clinical staff, timely submission of documentation, appropriate visit frequency based on patient needs, and ongoing authorization for continued care
• Collaborated with Education Department to develop and facilitate ongoing training
• Performed field visits with nurses with complex cases, for specific skill training, and annual performance reviews
• Reviewed OASIS-C assessments for accuracy
• Reviewed timed tasking tools to ensure justification of requested home health hours.