Leslie Crossley

Primary Responsibilities:

• Front Facing Practice Level Leadership
• Targeted Quality Improvement
• Gaps in Care Closure
• Relationship Management, Internal and External
• Community Engagement and Interaction
• Provider and Practice Education, Quality Oriented Health Topics
• Supports effective deployment of program at the practice level through strategic partnerships with participating practitioners and practice staff while assessing trends in quality measures and identifying opportunities for quality improvement
• Designs practice level quality transformation through targeted clinical education and approved materials related to HEDIS / State Specific quality measures for provider and staff education during field visits. Materials additionally include information from local, state, and national departments of health on key health related issues (understanding, exploring, educating, and facilitating on a local level)
• Serves as subject matter expert (SME) for assigned HEDIS / State Measures, preventive health topics, leads efforts with clinical team to research and design educational materials for use in practitioner offices; serves as liaison with key vendors supporting HEDIS / State Measures; consults with vendors to design and implement initiatives to innovate and then improve HEDIS / State Measure rates
• Supports state specific medical record collection and abstraction processes to drive optimum measurement and quality metric reporting during ambulatory medical record review, HEDIS data collection, or for other focus studies as directed by the Plan Quality Director
• Supports quality improvement program studies with work that ranges from accessing and analyzing provider records, maintaining databases, and researching to identify members’ encounter history
• Participates, coordinates, and/or represents the Health Plan at community-based organization events, clinic days, health department meetings, and other outreach events focused on quality improvement, member health education, and disparity programs as assigned.
• Identifies population-based member barriers to care and works to identify local level strategies to overcome barriers and close clinical gaps in care
• Reports individual member quality of care concerns or trends of concern to the Health Plan Quality Director
• Coordinates and performs onsite clinical evaluations through medical record audits to determine appropriate coding and billing practices, compliance with quality metrics, compliance with service delivery and quality standards
• Investigates gaps in clinical documentation where system variation has impact on rate calculation, provides feedback to appropriate team members where issues are verified, and monitors resolution to conclusion
• Based on medical record audit findings, provides follow-up education, practitioner intervention, and measurement as needed to drive quality improvement
• Educates providers and office staff on proper clinical documentation, coding, and billing practices, state-mandated quality metrics specifications, provider profiling and pay for performance measurement, and medical record review criteria
• Supports continuum of member care by identifying members in need of health education and/or services (case management, etc.) and refers members to the appropriate internal departments per policy
• Documents and refers providers’ non-clinical/service issues to the appropriate internal parties, to include Provider Relations and the Plan Chief Medical Officer
• Works with providers on standards of care, and advises providers on established clinical practice guidelines, and appropriate documentation and billing consistent with state specific measures and technical specifications
• Participates in or coordinates with other department projects as needed
• Needs to work independently and within an integrated team in a highly matrixed environment
• May do additional duties as assigned
• Developed, tracked and analyzed variance of key performance measurements.
• Leveraged analytical tools to provide insight and enhance performance.
• Monitored key performance indicators and built processes to support providers performance and growth.

• Assisted members in high volume inbound call center with any and all matters
• Efficiently communicated through email, calls, and team meetings with co-workers and members
• Developed implements and maintained product documentation templates
• Achieved documentation requirements for new or enhanced products
• Verified information, explained benefits, interpreted contracts, looked-up provider information, and researched claim issues
• Assisted helping people who are eligible for Medicare achieve the Medicare plan that meets their needs and aiding them with enrollment process of Medicare Advantage plans, Medicare Cost Plans and Medicare Supplement Plans
• Worked with multiple software applications and Express Scripts for pharmacy claims and issues
• Reviewed documentation for authorizations.
• Served as a subject matter expert on various aspects of health plans during team meetings and training sessions, increasing overall knowledge within the department.
• Implemented new strategies for tracking member feedback, leading to more effective problem-solving processes.
• Participated in ongoing training programs to stay current on industry trends, regulations, and best practices for optimal job performance.
• Maintained up-to-date knowledge of government programs such as Medicare and Medicaid, enabling accurate guidance for eligible members seeking enrollment assistance.

• Communicated effectively and professionally with both internal and external customers to resolve questions and issues
• Provided front-line phone customer service to policyholders, beneficiaries, agents, and internal customers
• Processed pension and structured settlement annuities and maintained a solid working knowledge of the insurance industry
• Collaborated with management or other team members as appropriate to proactively address service issues and concerns.

• Assisted customers with inquiries; Opened new checking and savings accounts; Trained new hires; Backup to branch manager; Handled all day to day activities.

• Seated and dismissed patients; Assisted with new patient, comprehensive, limited and emergency exams; Proficiently arranged dental instruments and materials; Assisted Dentist in conducting four-handed chair side procedures; Sterilized instruments and operatories; Performed panoramic radiographs; Assisted in extractions, Expose and Bond; Implants; Cosmetic procedures.

• Assisted customers with inquiries; Opened new checking and savings accounts; Managed loans, Mortgages, CD's, and IRAs; Balanced ATM's and Vaults; Responsible for opening/closing.

• Handled all transactions and balanced ATM; Promoted to Lobby Coordinator and Title Clerk; Prepared title work and bank drafts, filing, answering phones; Promoted to P.C
• Loan Officer where I assisted with loans, mortgages and opening of accounts; Promoted to Saturday Supervisor where I supervised employees and all transactions for the bank.

• Responsible for opening new accounts; Answered multi-line phone; Filing; Ordering supplies.