Mary Kathryn Griggs

Lead operational oversight for behavioral health peer review, retrospective review, and appeals processes supporting utilization management and regulatory compliance requirements.

• Manage remote team of 10 specialists (clinicians and non-clinicians) responsible for peer reviews, retrospective reviews, and appeals processing
• Oversee operational volumes including 400–500 peer reviews per month, 500–600 retrospective reviews per month, and approximately 350 appeals annually
• Maintain 100% timeliness for appeals processing and full compliance with contractual turnaround time requirements
• Achieve 100% audit success rate across NCQA, URAC, and health plan partner audits

• Analyze denial trends and collaborate with health plan partners and internal stakeholders to identify root causes and implement process improvements
• Serve as primary liaison to Independent Review Organizations (IROs) for external review processes
• Provide subject matter expertise to executive leadership for operational initiatives and cross-departmental projects
• Coordinate staff education, training, and onboarding for clinical and operational teams

• Partner with Workforce Management to conduct time studies and staffing model analyses supporting high-volume clinical operations
• Implement productivity reporting frameworks to support performance monitoring and operational planning
• Introduce changes to portal forms and EMR workflows that improved efficiency, reduced documentation errors, and lowered administrative burden
• Foster collaborative relationships with health plan clients to proactively address operational concerns and improve service delivery

• Supported operational integration during organizational acquisitions and onboarding of new health plan partners
• Led training initiatives for clinical and operations staff supporting new lines of business and program launches
• Collaborated with leadership to ensure operational readiness and compliance with contractual and accreditation standards

Provided clinical supervision and administrative oversight for a 24/7/365 behavioral health call center supporting utilization management, screening, and referral services.

• Led hiring, onboarding, and performance coaching for clinical staff
• Achieved 100% performance goal attainment across all direct reports during first two years in role
• Partnered with Workforce Management and IT to identify reporting discrepancies and implement operational improvements
• Oversaw monthly auditing and reporting for productivity and performance metrics
• Contributed to staffing model improvements that reduced overall staffing footprint
• Developed improved onboarding processes for new employees
• Participated in leadership initiatives related to program development and operational strategy

Provided leadership and escalation support for national behavioral health call center operations.

• Served as first escalation point for clinicians and operational staff
• Conducted utilization management case audits and quality reviews
• Assisted leadership with interviewing, hiring decisions, and staff performance evaluations
• Selected to train utilization management staff for new lines of business
• Mentored and trained new employees

Delivered integrated case management and utilization management services for behavioral health members.

• Conducted behavioral health assessments and coordinated care plans to reduce acute care readmissions
• Facilitated peer-to-peer physician reviews and coordinated care transitions
• Managed dual caseloads supporting both case management and utilization management functions
• Promoted to team leadership role based on performance

Directed social services operations for a 130-resident sub-acute rehabilitation and long-term care facility.

• Led interdisciplinary care planning and discharge coordination
• Conducted psychosocial, cognitive, and behavioral assessments
• Coordinated care with physicians, families, and community providers

• Coordinated patient assessments to identify social, emotional, and financial needs.
• Developed and implemented individualized care plans in collaboration with multidisciplinary teams.
• Provided crisis intervention support to patients and families during critical situations.
• Advocated for patients' access to community resources and healthcare services.
• Facilitated discharge planning to post-acute care settings
• Provided group therapy for geriatric psychiatry patients