Malissa C. Espinoza

• Leads a multidisciplinary health care services team of 51 employees.
• Tracked and trended high-utilization patterns for vulnerable populations to flag risks and guide targeted interventions (Perinatal/Postpartum, CARA, Medically Fragile, IDD, Native Americans).
• Directs and oversees case management/disease management/care transitions and specialty programs.
• Developed and implemented standardized protocols for clinical and non-clinical team activities, facilitating integrated proactive care review and management.
• Develops and promotes interdepartmental integration and collaboration to enhance clinical services.
• Develops, implements and monitors all day-to-day operations and employees for care coordination services delivery.
• Led committees, task forces, work groups, and multidisciplinary teams to promote standardized Molina enterprise-wide approach to Care Management programs.
• Contributed to care coordination training initiatives to improve service delivery.
• Develops and mentors HCS leaders including clinical and non-clinical Managers and Supervisors.
• Led efforts to design and develop all care management and coordination services with Molina’s Centers of Excellence team.
• Executed the strategic direction for care coordination that aligns with the long-term vision and goals for improved health outcomes for all vulnerable populations.
• Established KPI dashboard to monitor care coordination metrics and flagged variances weekly.
• Coached care coordinator leaders on the importance of motivational interviewing, improving member engagement during calls.
• Implemented best practices for review process for high-risk members in ICT rounds, decreasing avoidable hospital readmissions.
• Implemented structured audit protocol for care plans, uncovering documentation gaps and prompting targeted retraining.
• Implemented case staffing rounds with social work and behavioral health to resolve complex barriers to care.
• Led the IT team in data required to produce an improved member care plan in which became a pilot for the Molina Enterprise.
• Led monthly quality reviews of care coordination charts, identifying documentation gaps and corrective action items.
• Led NCQA audits for Care Coordination and maintained NCQA accreditation for the New Mexico health plan.
• Led the Critical Incident Team for member safety and quality-of-care events, guiding rapid triage and escalation.
• Directed root-cause reviews and corrective action plans, improving follow-up and preventing repeat incidents.
• Owned six regulatory reports and annual supplements, delivering accurate submissions and coordinating data validation across teams.
• Developed and updated all Healthcare Services policies and procedures and chaired the Healthcare Services committee for approvals.
• Develops and promotes interdepartmental integration and collaboration to enhance clinical services.
• Collaborates with and keeps VP of Healthcare Services informed of operational issues, staffing, resources, system, and program needs and presents solution action plan for issues.
• Develops, implements and/or monitors standardized protocols for clinical and non-clinical team activities to facilitate integrated proactive care review and management.
• Develops and mentors HCS leaders including clinical and non-clinical Managers and Supervisors.
• Leads the overall operations of Delegation of Care Coordination with contracted providers to ensure contractual alignment and overall health outcomes.
• Executed strategic direction for care coordination, aligning initiatives with long-term vision and goals to improve health outcomes for vulnerable populations.
• Established KPI dashboard to monitor care coordination metrics and flagged variances weekly.
• Coached care coordinator leaders on the importance of motivational interviewing, improving member engagement during calls.
• Implemented best practices for review process for high-risk members in ICT rounds, decreasing avoidable hospital readmissions.
• Implemented structured audit protocol for care plans, uncovering documentation gaps and prompting targeted retraining.
• Implemented case staffing rounds with social work and behavioral health to resolve complex barriers to care.
• Led the IT team in data needed to produce improved member care plans that became a pilot for the Molina Enterprise.
• Led monthly quality reviews of care coordination charts, identifying documentation gaps and corrective action items.

• Led Clinical Delegation meetings, ensuring smooth operation of delegation process across departments.
• Developed and led Process Committee to enhance case management processes.
• Conduct 1:1 biweekly employee touchpoints to support staff on any complex issues.
• Created and trained staff on departmental job aids, workflows, and documents.
• Conduct Case Management audits for quality and NCQA compliance.
• Supported business operations to achieve deliverables during leadership transition.
• Operationalized new Paramedicine program to improve engagement and health outcomes for high risk members.

• Acted as a liaison between all departments and Risk Management to assist in preventing and investigating risk-related events.
• Managed lost property and patient belongings through the complaint and grievance process.
• Conducted daily morning rounds with Charge Nurse on all hospital floors to identify and address rising risks.

• Led and managed a team of 17 employees to achieve optimal quality standards, positioned team members to use their talents, and helped support individual goals that in turn relate to the overall business vision.
• Identified breach in PHI, mitigating company risk in accordance with policy.
• Created a Delegated Entity Operations Manual, ensuring best practices for care coordination.
• Collaborated across departments to ensure successful Member attribution to delegated entity, addressing critical issues such as network growth and provider terminations.
• Built collaborative internal and external relationships with external stakeholders.
• Streamlined transition of care (TOC) process for newly enrolled and termed Members, facilitating transfer of clinical documents via sFTP.
• Refined antiquated internal processes to improve efficiency and quality in the Health Coordination department.

• Managed provider oversight for care coordination functions and developed regular reporting.
• Trained delegated entities on electronic case management platform used by BCBSNM to enhance operational effectiveness.
• Assisted in development and implementation of policies and procedures to ensure compliance and improve service delivery.

• Proficient in completing intake interviews, determining members’ requirements, and ensuring delivery of correlating health service for complex caseloads. Developed and implemented case management plans with members. Participated in Interdisciplinary Care Team (ICT) meetings, providing insight and direction where requested.
• Provided training and guidance to new Care Coordinators, enhancing their skills and knowledge.
• Conducted UAT testing for new software platform and collaborated in focus groups to enhance documents, workflows, and identify efficiency improvements.

• Established working relationships with case managers, medical directors, executive leaders, and health care providers. Reviewed benefit systems, authorizations, and denials for accuracy. Managed all travel arrangements for members that needed to consult with out-of-state physicians/surgeons and ensured continuity of care for members.
• Identified potential legal liability issues for services provided and escalated any concerns to management. Recommended changes for increased effectiveness and improved outcomes.
• Ensured adequate training for new and current staff and ongoing education support staff.

• Utilized plan software to generate care coordination reports.
• Assisted with requesting HCBS services (find provider, verify hours, and submit task for HCBS).
• Collaborated with management to enhance care coordination. Internal liaison for Appeals/Fair Hearing decisions.

• Compounded medications using aseptic technique and repackaged medications for nursing facilities. Oversaw inventory levels, implementing process that ensured 100% stock availability and increased inventory turnover.
• Delivered exceptional customer service, building rapport that enhanced client retention.
• Facilitated transfer of patient database to new the system, quickly mastering system and serving as Lead Trainer for remaining staff.

Graduated with Honors