LUISISNEY PEDROSO CRESPO

Work History

Staff VP Practice Management and Clinical Operations

Elevance Health

10.2022 - Current

Managed the clinical and operations team including, prior authorization, referrals, Disease Management, Case management, Transition of Care, along with the operations team developing and implementing strategies the align with industry standard and compliance.
Oversee clinical and operations performance patient satisfaction and quality improvements areas.
Develop and implement process to assess quality and risk management issues for quality improvement and reporting purposes.
Directs Case Management activities to control cost of high risk and high-cost populations.
Provide strategic guidance to Clinical leaders, clinic administrators, Pharmacy Director and OTC leaders to drive profitable growth and retention.
Lead and execute initiatives to plan, develop, deploy, and monitor business system models, metrics, and KPIs, ensuring maximum. operational and clinical effectiveness in clinical care, service excellence, workflow, quality outcomes, and financial viability.
Maintain compliance with Nationals Accreditations standards for utilization management functions, prior authorization, concurrent review units and all clinical and operations aspect of the business.
Serve as the primary P&L owner, with overall responsibility for the financial performance of all DN primary care centers, transportation, clinical team, Pharmacy and OTC.
Collaborate with the sales and retention team to enhance member engagement, customer satisfaction, and retention.
Manage delivery network transportation operations.
Establish standards of service and communication to enhance the member experience.
Ensure that practice policies and clinical operations align with industry standards and government regulations, administering effective workplace procedures.
Oversee the organization of patient records using standardized procedures to ensure compliance with laws and regulations.
Lead and oversee practice operations, including billing, debt collections, security, and occupational health and safety.
Set and enforce policies and practices for inventory management of medications and medical equipment.
Recruit, train, coach, counsel, and evaluate the performance of direct reports.
Developed and improved time management and organizational skills to maximise personal productivity.
Provides concurrent and retrospective reviews to insurance companies for authorization of services.
Lead the Utilization Review/Health Information Management Committee.
Responsible for Quality Improvement, Budgets, Policies/Procedures and daily intervention.
Facilitates appropriate utilization of hospital and community resources to provide cost-efficient care, provision of services and meet the requirements of regulatory and accrediting agencies.

APRN Faculty AND Program

Florida Regional University

07.2021 - Current

Deliver training sessions to students
Assess and grade homework, quizzes, tests, lab assignments, clinical paperwork, and other written work promptly
Provide timely corrections and feedback on homework, quizzes, tests, lab assignments, clinical paperwork, and other written work
Evaluate student performance based on course objectives and provide documented feedback
Collaborate with college administration, staff, and fellow faculty members to enhance overall college operations and student satisfaction
Report to the dean or assistant dean, with direct oversight provided by a course coordinator
Stay informed about agency/clinical policies, procedures, and expectations with assistance from agency/clinical personnel
Contribute to the ongoing development, implementation, and evaluation of programs and the College

APRN Faculty AND Program

Florida National University

08.2020 - Current

Deliver instructional sessions to students
Assess and evaluate homework, quizzes, tests, lab assignments, clinical paperwork, and other written assignments promptly
Provide timely feedback and corrections on homework, quizzes, tests, lab assignments, clinical paperwork, and other written work
Assess student performance against course objectives and offer documented feedback
Work collaboratively with college administration, staff, and fellow faculty members to enhance overall college operations and student satisfaction
Provide regular reports to the dean or assistant dean, with direct oversight from a course coordinator
Stay updated on agency/clinical policies, procedures, and expectations with guidance from agency/clinical personnel
Contribute actively to the ongoing development, implementation, and evaluation of programs and the College

Director Medical Management

Elevance Health

08.2020 - 10.2022

The Medical Management Director spearheads all medical management activities, prioritizing both operational efficiency and clinical excellence in utilization management, disease management, and case management functions.
Oversees personnel and ensures compliance with regards to regulatory agencies related to Discharge Planning, Utilization Review, Case Management, Social Services, Transitional Care processes.
Works closely with the Chief Medical Officer and Compliance Officer to devise and implement medical quality programs/policies, assess improvement opportunities, and collaborate with clinicians to execute initiatives effectively
Establishes comprehensive programs in case management, utilization review, quality and outcome management, and education to ensure the delivery of top-tier, cost-effective healthcare services
Nurtures and maintains strong relationships with clinicians, specialty clinicians, facility partners, and health plan medical directors & clinical teams
Provides unwavering support to the executive team and clinical staff in strategic planning, compliance, and process enhancement endeavors, aiming to deliver efficient, high-quality, and affordable care to all patients
Demonstrates a deep understanding of leveraging both data and clinical expertise in a fast-paced care delivery environment
Develop and implement comprehensive utilization management strategies aligned with organizational goals, including cost containment, quality improvement, and patient satisfaction.
Lead the clinical review process, including prior authorization, concurrent review, and retrospective review of patient care plans to assess medical necessity and appropriateness of services.
Establish and maintain utilization management policies and procedures based on clinical guidelines and industry best practices. Combined with Medicare, Medicaid or commercial regulations as applicable
Analyze utilization data to identify trends, areas of concern, and opportunities for improvement, developing strategies to improve the financial and quality performance of the organization.
Collaborate with physicians, nurses, and other healthcare providers to educate them on utilization management policies, promote appropriate care delivery, and address any concerns.

RN Grievances and Appeals Manager

Elevance Health-HealthSun Health Plans

11.2019 - 08.2020

Manage the monthly receipt and maintenance of grievance and appeals reports, maintaining a comprehensive database
Supervise and execute the Grievance and Appeal System for Medicare Enrollees Network
Address and resolve complaints and grievances from network enrollees, ensuring timely resolution between the enrollee and provider
Maintain accuracy of grievances and appeals and generate reports for board presentations
Coordinate prompt reviews and follow-ups on case review requests
Ensure compliance with CMS guidance and regulations
Develop and implement department policies and procedures

RN Grievances and Appeals Interim Manager

HealthSun Health Plans

03.2019 - 11.2019

Lead and manage the Grievance and Appeal System for Medicare Enrollees Network
Address and resolve complaints and grievances from network enrollees, ensuring timely resolution with providers
Maintain a Database of filed grievances and appeals, and compile reports for board presentations
Coordinate and supervise the fulfillment of Customer Service Requirements
Conduct thorough and prompt reviews, following up on all case review requests
Ensure compliance with CMS guidance and regulations
Develop and implement departmental policies and procedures

Grievances and Appeals Clinical Auditor, RN

HealthSun Health Plans

02.2018 - 03.2019

Evaluate and determine the quality of care in various cases
Assist G&A staff in categorizing and assessing cases
Analyze medical records to identify deviations from medical guidelines and care standards
Present case files to the Medical Management/Medical Director and Quality department for initial assessment
Identify and address trends or concerns with the Quality, Utilization Management, and Compliance Departments
Ensure compliance with HIPAA, OSHA, and other relevant regulations
Support upper management in decision-making processes regarding Clinical and Quality areas, including Risk Assessments and HRA processes

Grievances and Appeals Analyst

HealthSun Health Plans

09.2017 - 02.2018

Receive and categorize all incoming mail related to grievances and appeals, including faxes, claims, appeals, and clinical documents
Review each case file to determine the appropriate course of action and process
Process all grievances and appeals in compliance with regulatory guidelines, which includes contacting enrollees and providers, conducting research on Medicare regulations, reviewing claims and authorizations, and examining medical records and legacy system documentation
Prepare and submit case files to the Independent Review Entity (IRE) as mandated by regulations, and serve as the primary point of contact for each case file submitted to the IRE

Administrator

Clínica Las Mercedes

06.2016 - 08.2017

Guarantee the quality and care standards of services provided by our physicians, therapists, dentists, and optometrists within the office
Lead various projects focused on improving patient satisfaction and ensuring a seamless client experience
Coordinate conferences, meetings, and special events when required
Develop and implement policies and procedures to optimize operations and uphold standards
Supervise both paper and electronic filing systems for patient and employee records
Oversee clinical finances, including payroll and budget management, for all clinical operations

HEDIS Coordinator/Medical Assistant

Continucare Humana

06.2015 - 06.2016

Lead the coordination of HEDIS processes and devise plans to elevate scores
Establish procedures for requesting and evaluating member compliance reports for each HEDIS measure, identifying avenues for enhancement
Collaborate with providers and internal departments on rate investigation and validation efforts, maintaining thorough documentation and evidence
Conduct quality audits and uphold data integrity and process controls to ensure adherence to standards
Maintain and update clinical quality metrics to align with evolving practices and benchmarks

Physician Coordinator

C.M.A Clinic

06.2014 - 06.2015

Ensure patient confidentiality and trust by meticulously completing and safeguarding medical records, including diagnostic and procedure coding, while upholding the confidentiality of patient information
Schedule patient appointments and offer assistance to patients prior to their visits
Provide support to the medical staff by managing electronic medical records
Coordinate patient flow to maintain a consistent workflow for MD/NP/PA appointments
Conduct audits to ensure compliance with medical records regulations
Collaborate with the Medical Director to establish call and coverage schedules
Collect data for quality assurance and other analytical needs
Efficiently manage daily paperwork by receiving and organizing it
Assist in orienting new medical staff, providing training on electronic medical records, and facilitating facility tours
Maintain and update the physician handbook as needed

MD, Medical Advisor

ROEMMERS Laboratories

07.2013 - 01.2014

Maintained up-to-date knowledge on industry trends and regulations, ensuring accurate advice was provided to clients at all times.
Developed long-lasting relationships with clients to ensure consistent retention and loyalty.
Participated in ongoing professional development opportunities to stay current with industry trends and best practices.
Increased client satisfaction, providing personalized investment advice based on thorough financial analysis.
Optimized operational efficiency by implementing CRM system tailored to advisory services.

MD, PAHO/Consultant

PAHO

03.2013 - 09.2013

Evaluated client needs and expectations, establishing clear goals for each consulting engagement.
Collaborated with cross-functional teams to successfully deliver comprehensive solutions for clients.
Managed client relationships through regular check-ins and updates on project progress.
Assisted clients in navigating complex industry challenges with strategic recommendations.
Identified areas of improvement for clients'' operations, implementing targeted solutions to increase productivity.
Developed innovative strategies for clients, resulting in increased revenue and business growth.
Analyzed data sets to identify trends and opportunities for process improvements within client organizations.

MD, Resident Physician, Surgery Department

Santa Clara

10.2012 - 03.2013

Evaluated the effectiveness of current treatments by participating actively in morbidity/mortality conferences, generating constructive feedback for improvement.
Collaborated with multidisciplinary teams to ensure optimal patient outcomes and continuity of care.
Diagnosed and treated patients suffering from chronic conditions.
Prioritized urgent cases efficiently by utilizing triage skills, resulting in timely treatment for critically ill patients.
Implemented evidence-based practice guidelines to optimize patient outcomes and maintain adherence to industry standards.
Performed various diagnostic procedures competently while minimizing discomfort for patients during their evaluation process.
Participated in quality improvement initiatives, resulting in increased efficiency within the medical unit.
Presented case studies at conferences, sharing insights on challenging cases with peers from around the country.
Improved patient care by developing comprehensive treatment plans tailored to individual needs.

MD, Assistant Profesor

Instituto Superior de Ciencias Médicas

09.2009 - 02.2013

MD, Quality Control Director

Cuban Technical Cooperation

09.2010 - 09.2012

MD, Vice Medical Director

Health Department

09.2009 - 08.2010

Summary

Overview

Work History

Staff VP Practice Management and Clinical Operations

APRN Faculty AND Program

APRN Faculty AND Program

Director Medical Management

RN Grievances and Appeals Manager

RN Grievances and Appeals Interim Manager

Grievances and Appeals Clinical Auditor, RN

Grievances and Appeals Analyst

Administrator

HEDIS Coordinator/Medical Assistant

Physician Coordinator

MD, Medical Advisor

MD, PAHO/Consultant

MD, Resident Physician, Surgery Department

MD, Assistant Profesor

MD, Quality Control Director

MD, Vice Medical Director

Education

MASTER OF SCIENCE - Advance Practice Registered Nurse FNP-C

REGISTERED NURSE -

FAMILY MEDICINE SPECIALIST -

MEDICAL DOCTOR -

Skills

Accomplishments

Timeline

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