MERIBETH CIPRIANO
Nursing
Killingworth,CT
Summary
Experienced nursing professional offering proven clinical knowledge, natural interpersonal strengths, and technical abilities. Skilled in patient and provider education and case management. Offering an in-depth understanding of medical care requirements and best practices. Quality-focused and efficiency-driven leader.
Overview
16
16
years of professional experience
Work History
Manager, Clinical Operations Delegation
Connecticare
Farmington, CT
08.2021 - Current
- Manage a team of 9 clinical and non-clinical personnel responsible for the function for Delegation Oversite of utilization and case management functions
- Oversee the development of NCQA and Regulatory audit tools., reports, reports analysis, and presentation of results
- Ensure continued adherence to organizational accreditation requirements
- Monitor delegate documentation for compliance with applicable requirements
- Monitor Corrective Action Plans
- Perform root cause analysis and impact analysis, risk mitigation
- Develop, implement, and enhance processes
- Oversite of delegates for NCQA, State and Federal audits
- Participate in NCQA survey accreditation and review
- Develop and deliver training as necessary.
- Expanded cross-functional organizational capacity by collaborating across departments on priorities, functions and common goals.
- Accomplished multiple tasks within established timeframes.
- Applied customer feedback to develop process improvements and support long-term business needs.
- Maintained professional, organized and safe environment for employees and patrons.
- Reduced process bottlenecks by training and coaching employees on practices, procedures and performance strategies.
- Delivered feedback to decision-makers regarding employee performance and training needs.
- Onboarded new employees with training and new hire documentation.
- Cross-trained existing employees to maximize team agility and performance.
- Developed and maintained relationships with customers and suppliers through account development.
Clinical Operations Delegation Manager
Connecticare
Farmington, CT
10.2019 - 08.2022
- Direct accountability for the oversite of utilization and care management delegated services
- Track and monitor vendor dashboards and scorecards
- Oversite of delegates for NCQA, State and Federal audits
- Participate in NCQA survey accreditation, CMS audits and review
- Measures and evaluates vendor performance including Key Performance guarantees, SLAs compliance with NCQA, State, and Federal Standards
- Develop, implement ongoing process improvements to ensure that there are no gaps in performance
- Liaison between medical management, internal stakeholders, and vendors
- Ensure continued adherence to organizational accreditation requirements
- Monitor delegate documentation for compliance with applicable requirements
- Conduct regular audits with review of policies, procedures, and medical records
- Monitor Corrective Action Plans
- Perform Root Cause and Impact Analysis
- Participate in delegate audits by external agencies
Senior Field Case Manager
Optum Complex Case Management
Rocky Hill, CT
01.2014 - 05.2019
- Performs in depth medical chart review of new members of both long- and short-term members
- Developed presentations of clinical content including training to large and small groups of clinicians, developing training to fit specific provider's needs
- Collaborated with clinical team for care coordination from skilled nursing facilities, benefit coordination
- Educated Skilled nursing facility staff and clinical staff on the Optum Product to establish collaborative relationships with external and internal participants
- Solved complex problems and conducts moderately complex analyses to help drive positive results
- Managed quality assurance program including on site evaluations, internal audits for HEDIS/STAR measures per CMS guidelines
- Researched and implemented initiatives and provided Continuous Documentation Improvement to promoted quality and improve efficiency and timeliness
- Worked with Sales, to improve operations and provide exceptional customer service
- Co-managed team of 14 Professional staff members
Utilization Review Transition Case Manager
United Health Care
Rocky Hill, CT
09.2007 - 01.2014
- Coordinated appropriate level of care for clinical operations and medical management activities across the continuum of care from assessing and planning to implementing, coordinating, monitoring and evaluating for the Commercial, Medicare and Medicaid population
- Conducted Case management, health education, coaching and solving moderately complex problems and conducts moderate complex analysis
- Clinical medical necessity review against Clinical Guidelines for acute care and outpatient services
- Performed clinical chart reviews of current inpatient services and determined medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination
- Clinical EHR integration
Education
Bachelor of Science - Nursing
Salve Regina University, Heart University
Skills
Microsoft Word, Excel, PowerPointundefined
Accomplishments
- Provider and Member Education
- Utilization Management
- Population Health Management
- Quality Management
- Continuous Documentation Improvement
- Process improvement
- Strong clinical judgment
- Clinical file review and auditing
- NCQA Accreditation
- Vendor and Account Management
Timeline
Manager, Clinical Operations Delegation
Connecticare
08.2021 - Current
Clinical Operations Delegation Manager
Connecticare
10.2019 - 08.2022
Senior Field Case Manager
Optum Complex Case Management
01.2014 - 05.2019
Utilization Review Transition Case Manager
United Health Care
09.2007 - 01.2014
Bachelor of Science - Nursing
Salve Regina University, Heart University
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