Summary
Overview
Work History
Education
Skills
Certification
Summaryofqualifications
Timeline
Generic

MAUREEN K. O’KEEFE

Frankfort,IL

Summary

28 years Clinical Nursing Experience 16+ years extensive managed care/healthcare experience across multiple Lines of Business (Commercial/ACA Medicare Advantage) which includes positions in Clinical setting, bedside nurse and charge nurse, Utilization & Case Management nurse, Manager of Holistic Health Management, Director/Sr Director of Clinical Operations and Wellness Product Team Associate Manager Clinical Medical Management 11+ years of Leadership Experience

Results-driven professional with extensive experience in leadership and strategic oversight. Adept at driving organizational success through effective team collaboration and dynamic problem-solving. Recognized for adaptability and keen focus on achieving objectives.

Overview

27
27
years of professional experience
1
1
Certification

Work History

Associate Director, Clinical Operations

Optum
12.2023 - Current
  • Worked with Care Delivery Organizations in identifying opportunities through data analytics to improve patients’ health outcomes while still supporting the well-being of health care workers
  • Lead teams of specialists in creating care guides managing COPD, CHF, Recurrent UTI sharing with CDO providers to close the gap on disease management and remove care variation
  • Developed an enterprise best in class clinical model utilizing evidence-based medicine, risk stratification, clinical governance, and unified program measurements to establish a physical & behavioral integration business model
  • Partnered with Vendor Management team in identifying opportunities for pilots in managing member outcomes to drive down cost and provide more end-to-end holistic care
  • Interface with Clinical Affordability pillars and Regional Care Delivery Organization physician leadership teams to coordinate the buildout and deployment of Integrated Primary ED Diversion, Social Determinants of Health, and High Risk/High Touch Clinical Model infrastructure across the enterprise
  • Collaborate with clinical leadership groups and project teams to support and lead product introduction activities and assess potential vendor partnerships

Sr Director, Clinical Operations

BlueCross Blue Shield of Illinois
01.2020 - 12.2023
  • Responsible for management, administration, and clinical operations oversight for a dedicated team of nurses performing utilization management case management
  • Wellness coaches and consultants and non-clinical support staff
  • Staff includes up to 90 clinical and non-clinical resources
  • Supporting multiple client accounts across 5 enterprise States and LOB including FI and ASO serving 7 M members
  • Provide leadership to and is accountable for the performance of managers and clinical level staff
  • Owns end to end process and program performance, driving high quality execution and achieving affordability outcomes
  • Manage functional, market level and strategy plans, production and/or organizational priorities including medical management, financial accountability, customer and provider satisfaction, quality improvement
  • Lead AOC & HEDIS measure initiatives in IL plan and clinical programs focused on high dollar complex medical conditions to drive affordability targets
  • Collaborate with other departments cross functionally including Medical Directors, sales, reporting, account management, finance, senior leadership, and other stakeholders
  • Developed and implemented organizational pilots; IT documentation platform and was lead on adopting the Wellframe vendor app to enhance member and clinician interaction
  • Readmission, participate in program development, digital engagement tool/platforms, and refinement of scalability across the enterprise
  • Manage towards corporate API goals and individual ASO group P&L
  • Oversee care coordination functions and ensure compliance with URAC, NCQA, and Department of Insurance accreditation standards
  • Audit prep and participation for URAQ, NCQA, employer group audits
  • Create and carry out Population Health Management documents and process required for the FI membership and NCQA
  • Responsible for facilitating communication and directing the operations of multiple teams
  • Design and implement strategies that drive process improvement and enhance operations, reduce operating costs, and standardize best practices across the organization

Director, Clinical Operations

BlueCross Blue Shield of Illinois
07.2018 - 01.2020
  • Responsible for management, administration, and clinical operations oversight for a dedicated team of nurses performing utilization management case management
  • Staff includes up to 90 clinical resources
  • Provide leadership to and is accountable for the performance of managers and clinical level staff
  • Owns end to end process and program performance, driving high quality execution and achieving affordability outcomes
  • Manage functional, market level and strategy plans, production and/or organizational priorities including medical management, financial accountability, customer and provider satisfaction, quality improvement
  • Participated in development of new documentation platform, Smart UM, continue to provide input and data post implementation to enhance development and troubleshoot as issues arise
  • Collaborate with other departments cross functionally
  • Oversee care coordination functions and ensure compliance with URAC, NCQA, and Department of Insurance accreditation standards
  • Responsible for facilitating communication and directing the operations of multiple teams
  • Design and implement strategies that drive process improvement and enhance operations, reduce operating costs, and standardize best practices across the organization
  • Manage towards corporate API goals and individual ASO group P&L
  • Implemented innovative solutions to solve complex problems, resulting in increased productivity and streamlined operations.
  • Proactively identified potential risks and implemented mitigation strategies to minimize negative impacts on projects or business operations.

Senior Manager, Clinical Operations

BlueCross Blue Shield of Illinois
06.2015 - 08.2018
  • Responsible for management, administration, and clinical operations oversight for a dedicated team of up to 47 nurses and non-clinical staff, performing utilization management case management and behavioral health services
  • Provide leadership to and is accountable for the performance of managers and clinical level staff
  • Owns end to end process and program performance, driving high quality execution and achieving affordability outcomes for up to 7million members
  • Manage functional, market level and strategy plans, production and/or organizational priorities including medical management, financial accountability, customer and provider satisfaction, quality improvement
  • Part of the Smart UM documentation system development team continue to provide input and data to enhance development
  • Collaborate with other departments cross functionally
  • Direct operations in finding efficiencies for multi plan denials team to meet timelines
  • Oversee care coordination functions and ensure compliance with URAC, NCQA, and Department of Insurance accreditation standards
  • Proficient in NCQA, URAC, and TDI standards
  • Responsible for file prep and participation in URAC and NCQA audits; lead the corrective action plan from audit results across multi-functional areas
  • Responsible for facilitating communication and directing the operations of multiple teams
  • Design and implement strategies that drive process improvement and enhance operations, reduce operating costs, and standardize best practices across the organization
  • Drive staff engagement
  • July 2017 to Jan 2018- Oversight of the addition of a 500K member group to the Texas plan, ERS; systematically analyze problems, draw relevant conclusions, and devise appropriate course of action
  • Continue to collaborate across ERS with Medical directors, senior leaders, sales, account management, and other key stakeholders

Unit Manager, Clinical Operations

BlueCross Blue Shield of Illinois
12.2013 - 06.2015
  • Directly supervised 15 staff in a variety of clinical operations including utilization management and clinical social work
  • Responsible for onboarding new staff, ensuring staff meet/exceed goals
  • Developed and implemented departmental processes for SNF team which has decreased length of stay helping manage cost
  • Maintained URAC and NCQA accreditation standards
  • Collaborated with legal for PDN requests
  • Participated in MD collaboration

Care Coordinator UM/CM III

BlueCross Blue Shield of Illinois
11.2010 - 12.2013
  • Neonatal ICU team lead of 4 clinicians
  • Assisted in the development of original SOP and workflows for the IL NICU team
  • Performed Utilization Management and Complex Case Management
  • Responsible for daily coordination and communication within the team to meet departmental regulations
  • Facilitated Medical Director weekly rounds for high dollar claimants
  • Participated in external client audits

Care Coordinator UM/CM II

BlueCross Blue Shield of Illinois
05.2008 - 11.2010
  • Responsible for utilization review, discharge planning, episodic case management and pre-admission/post-discharge counseling for IL UM PPO membership
  • Independently worked to complete daily tasks as well as being a mentor staff and leading projects/corporate initiatives
  • Independently met my daily goal of 30 reviews and exceeding end of year goals

Charge Nurse/Staff Nurse

Advocate Christ Hospital & Medical Center
08.1998 - 08.2007
  • Managed staffing and daily operations utilizing critical thinking and problem-solving skills while assuming patient care assignments of a 25 bed Labor and Delivery Unit
  • Preceptor of new nurses for over 10 years
  • Chair of Unit Policy Council
  • Trained in all areas of labor and delivery

Education

Certification - Change Management

Lake Forest Graduate School of Management
Chicago, IL

Bachelor of Science - Nursing

Lewis University
Romeoville, IL
12.1995

Bachelor of Science - Early Childhood Education

Illinois State University
Normal, IL
05.1990

Skills

  • Healthcare Strategy/Process Improvement
  • High Risk High Touch Membership Programs
  • Work freely in virtual environment
  • Product management
  • Effective communication skills
  • Driving and executing quality outcomes
  • Planning and prioritizing
  • Strategic thinker
  • Team collaboration and leadership
  • Technical implementation
  • Operations management
  • Organizational development
  • Utilization Review, Care Management, Adverse determinations, Appeals

Certification

Certified Managed Care Nurse (CMCN), 2010

Summaryofqualifications

28 years, 16+ years, 11+ years, Healthcare Strategy, High Risk High Touch Membership Programs, Utilization Management and Care Management, Quality and Accreditation Oversight: HEDIS/URAQ/NCQA, Adverse determination, appeals, claims review, Maternal Fetal Medicine/labor & deliver/special care nursery, Management/leadership and oversight, Work freely in virtual environment, Effective communication skills, Driving and executing quality outcomes, Critical Thinking, Project Integration, Planning and prioritizing, Staff training and development, Strategic thinker

Timeline

Associate Director, Clinical Operations

Optum
12.2023 - Current

Sr Director, Clinical Operations

BlueCross Blue Shield of Illinois
01.2020 - 12.2023

Director, Clinical Operations

BlueCross Blue Shield of Illinois
07.2018 - 01.2020

Senior Manager, Clinical Operations

BlueCross Blue Shield of Illinois
06.2015 - 08.2018

Unit Manager, Clinical Operations

BlueCross Blue Shield of Illinois
12.2013 - 06.2015

Care Coordinator UM/CM III

BlueCross Blue Shield of Illinois
11.2010 - 12.2013

Care Coordinator UM/CM II

BlueCross Blue Shield of Illinois
05.2008 - 11.2010

Charge Nurse/Staff Nurse

Advocate Christ Hospital & Medical Center
08.1998 - 08.2007

Certification - Change Management

Lake Forest Graduate School of Management

Bachelor of Science - Nursing

Lewis University

Bachelor of Science - Early Childhood Education

Illinois State University

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MAUREEN K. O’KEEFE