JENNIFER SMITH MSN, MBA, CPHQ, CCM, CPC-A,
Ocala,FL
Summary
Quality management professional with extensive experience in leading quality assurance teams and implementing process improvements. Recognized for fostering collaborative environments and driving results through innovative quality strategies. Known for adaptability and reliability, ensuring consistent quality outcomes.
Overview
28
28
years of professional experience
1
1
Certification
Work History
Senior Quality Manager, Population Health
AdventHealth
10.2021 - Current
- Responsible for overseeing the quality care gaps of 500,000 value-based payor contract members
- Achieved $5.2 million in shared savings in 2023
- Responsible for the education and training of HEDIS quality measures to providers and staff members
- Performs provider medical record reviews, abstraction, and data for HEDIS quality measures
- Strong critical thinking/problem-solving skills
- Collaborates with interdisciplinary teams and resources to improve processes
- Create project plans and responsible for the implementation and follow-through of the projects
- Tools utilized include electronic health record, claims system, clinical informatic reports, national guidelines and benchmarks, CMS regulations, and other applicable resources
- Develops, assesses, plans, implements, and evaluates procedures and processes for the organization
- Provides continuing education, process improvement, and change management
- Actively involved in future planning and strategic development of the quality department needs
- Includes policy development, program development, ongoing audits for the Population Health organization, and quality improvement efforts
- Identify high-level clinical and other data trends to recommend courses of action to reduce cost and increase quality outcomes
- Work closely with payers to improve CAHPS scores and overall STARS performance rating
- Perform analysis of populations and program data to identify key areas of cost improvement opportunity for Value-Based Payment Models
- Proficient in MS Office, Word, Excel, Power Point, Vizio, Teams, and some experience utilizing PowerBI
- Strong interpersonal skills that promotes teamwork and collaboration with other teams
- Able to motivate employees to attain program and organizational goals
- Responsible for the hiring and overseeing the training process of new employees in the quality department
- Achieved departmental objectives by setting clear performance metrics and regularly reviewing progress against targets.
- Implemented Lean Six Sigma methodologies to streamline processes, increasing productivity while maintaining high-quality standards.
- Championed a culture of continuous learning within the organization, promoting ongoing professional development opportunities for staff members at all levels.
Care/Utilization Manager, National Post-Acute Care Management
United Healthcare Group
07.2019 - 05.2021
- Perform Skilled Nursing Facility (SNF) assessments on patients using clinical skills and appropriate measurement tools, such as nH Predict, nH Outcome, InterQual / Mcg and CMS criteria, upon admission to SNF and periodically throughout the patient stays
- Issue NOMNC, monitor appeals, and issue DENC letters
- Review targets for Length of Stay (LOS), target outcomes, and discharge plans with providers and families
- Ensure compliance with all federal and state regulations, accreditation organizations, and client requests
- Collaborate with Optum Enterprise Clinical Services Medical Directors on performing utilization management
- Complete all SNF concurrent reviews, updating authorizations on a timely basis
- Collaborate effectively with the patient’s healthcare teams to establish an optimal discharge
- Assure patient progress toward discharge goals and assist in resolving barriers
- Participate weekly in SNF Rounds providing accurate and up-to-date information to the Medical Director
- Assure that appropriate referrals are made to the Health Plan, High-Risk Case Manager, and/or community-based services
- Engage with patients, families, or caregivers either telephonically or on-site weekly and as needed
- Attend patient/family care conferences
- Identify opportunities for improved communication or processes
- Participate in audit activities and meetings
- Monitored and coordinated care associated with BPCI-A patients
Regional Senior Population Management Advisor, Population Health
AdventHealth
08.2018 - 07.2019
- Utilized market intelligence and data to determine the size and scope of the network required to deliver high-quality services that meet the needs of the communities we serve, provide appropriate access, and ultimately lower the per capita cost of healthcare
- Onboarded providers for Provider Networks and affiliated payer networks/health plans to ensure the provider was informed and engaged related to essential information
- Articulated complex topics in a way that facilitates understanding, both among providers as well as other team members
- Educated providers regarding regional-specific quality and clinical improvement initiatives including clinical documentation integrity, HCC recapture, and HEDIS care gap closure
- Responsible for promoting and facilitating provider recruitment and presenting the value of participation in the network to small and large groups, in formal and informal settings
- Worked seamlessly, effectively, and in harmony with all internal teams including Population Health Services Organization, credentialing, experience center, quality and care integration, provider engagement education, analytics, contracting, and finance departments
- Team leader, collaborated closely with the Executive Director/Director to ensure team competency and engagement
- Worked with providers to resolve claim issues
- Responsible for maintaining operational knowledge of business intelligence tools and engaging other resources/teams as needed
- Responsible for maintaining and understanding assigned territory including market attributes, providers in the community, and other pertinent information
Clinical Quality Coordinator, Population Health
AdventHealth
07.2017 - 08.2018
- Worked with physician practices, hospital teams, and post-acute (PAC) providers in the ACO and CIN to manage the full continuum of care in the provider network
- Provided strategic insight about the hospital, employed, and community provider strategies, including areas of strength, weakness, and growth opportunities, resulting in better alignment with internal Hospitalist groups and community physicians focusing on reducing care gaps and referring to a preferred list of specialists
- Established and maintained a post-acute preferred provider network in conjunction with ACO and CIN regulations and bylaws
- Provided education to physicians and other referral sources regarding post-acute services and in-network utilization
- Reviewed readmission rates and readmission retention rates of post-acute providers and initiated discussions with providers to improve performance
- Provided monthly utilization reports to PAC providers and ACO leadership
- Acted as the liaison for the patients between the hospital and the PAC facilities for the ACO and the CIN
- Supported the goal of continuous quality improvement by making pertinent suggestions to improve efficiency and/or to contain costs, improve in-network utilization/readmissions, and improve customer service and customer satisfaction
Case Manager Supervisor
The Villages Regional Hospital
07.2015 - 07.2017
- Oversaw 35 full and part-time employees which consisted of case managers and licensed clinical social workers
- Oversaw the provision of case management services by consistently reviewing staff documentation and assisting with the coordination of care
- Responsible for determining the appropriateness of hospital admission; utilization of resources and medical necessity for continued stay
- Assured medical documentation accurately reflected the patient’s severity of illness
- Reviewed patient insurance, checked patient eligibility and evidence of coverage, coding, and billing paperwork for a smooth discharge process
- Assisted all case managers in coordinating DME services and home care services for patients
- Conducted quarterly evaluations and attended weekly meetings
- Responsible for training new staff, interviewing potential employees, and the hiring/termination processes
- Worked closely with nursing staff, physicians, patients, and family members
- Utilized Milliman and InterQual systems to evaluate continued stay requirements
- Played a key role in the development and implementation of organizational policies and procedures related to case management, ensuring alignment with best practice standards.
- Provided ongoing support to case managers in crisis situations, guiding them through problem-solving strategies and promoting best practice approaches.
- Increased client satisfaction with services by closely monitoring progress and adjusting case plans as needed.
- Managed budgetary responsibilities for the case management department, ensuring optimal allocation of resources based on client needs and program goals.
- Collaborated with interdisciplinary teams to develop holistic care plans addressing all aspects of clients'' lives.
Case Manager
HealthSouth Rehabilitation Hospital
02.2015 - 07.2015
- Managed a caseload of 15-20 patients
- Worked closely with the patients and family members or caregivers to plan a safe discharge
- Collaborated with interdisciplinary teams to develop patient care plans to establish a smooth discharge and transition of care
- Responsible for all DME and post-acute needs
Nursing Supervisor
HealthSouth Rehabilitation Hospital
05.2014 - 02.2015
- Responsible for nursing staff of the 50-bed acute rehab facility
- Collaborated with interdisciplinary teams to develop patient care plans to establish a smooth discharge and transition of care
- Responsible for onboarding and training nursing staff
- Supervised the care, treatment and services provided to patients by the nursing team
Logistics/Transportation Director
Custom Windows Systems
04.2005 - 09.2011
- Non-clinical management role
Customer Service Manager
Petsmart
08.1996 - 02.2000
- Non-clinical management role
Education
Master's - Business Administration - Healthcare Management
Western Governors University
10.2023
Master's - Nursing Leadership
Western Governors University
03.2019
Bachelor's - Nursing
Rasmussen University
06.2015
Associate - Nursing
Rasmussen University
Ocala, FL09.2012
Skills
- Utilization Management
- Leadership
- Customer Service
- Collaboration/Teamwork
- Organization
- Communication
- Problem-Solving
- Active-Listening
- Excellent researching skills
- Analytical mindset
- Performance monitoring
- Quality processes
- SOP review
- Problem-solving abilities
- Operational Efficiency
- Team building
- Training and Development
- Strategic Planning
- Time management abilities
- Workflow Optimization
- Project Management
- Root Cause Analysis
- Lean manufacturing principles
- Change Management
- Six Sigma Methodologies
Certification
- Certified Professional in Healthcare Quality (CPHQ)
- Certified Case Manager (CCM)
- Certified Six Sigma Green Belt
- Certified Professional Coder - Apprentice (CPC-A)
Timeline
Senior Quality Manager, Population Health
AdventHealth
10.2021 - Current
Care/Utilization Manager, National Post-Acute Care Management
United Healthcare Group
07.2019 - 05.2021
Regional Senior Population Management Advisor, Population Health
AdventHealth
08.2018 - 07.2019
Clinical Quality Coordinator, Population Health
AdventHealth
07.2017 - 08.2018
Case Manager Supervisor
The Villages Regional Hospital
07.2015 - 07.2017
Case Manager
HealthSouth Rehabilitation Hospital
02.2015 - 07.2015
Nursing Supervisor
HealthSouth Rehabilitation Hospital
05.2014 - 02.2015
Logistics/Transportation Director
Custom Windows Systems
04.2005 - 09.2011
Customer Service Manager
Petsmart
08.1996 - 02.2000
Master's - Nursing Leadership
Western Governors University
Bachelor's - Nursing
Rasmussen University
Associate - Nursing
Rasmussen University
Master's - Business Administration - Healthcare Management
Western Governors University