Sallie Shuskey
Denton,NC
Summary
Strategic thinker with a proven track record in quality service delivery at BluePeak Advisors, resulting in substantial enhancements in client satisfaction and compliance with CMS guidelines. Demonstrates strong collaborative problem-solving abilities and advanced computer proficiency, leading to innovative solutions that improved service quality and operational efficiency.
Overview
36
36
years of professional experience
Work History
Senior Health Plan Services Consultant
BluePeak Advisors
03.2023 - Current
- Developed client strategies to ensure client satisfaction.
- Aided in launching innovative client services.
- Worked jointly with groups to design complete solutions addressing CMS concerns.
- Monitored quality assurance metrics to ensure high standards of service delivery.
- Participated in training sessions on CMS audit readiness and policies.
- Guided clients on optimal practices for the MA Plan's Model of Care.
- Analyzed data trends related to CMS performance indicators.
- Prepared documentation such as user guides, manuals, tutorials, policies and procedures.
- Designed tailored packages meeting unique client needs and CMS guidelines.
- Implemented measures to comply with applicable legal frameworks.
- Discovered areas for process enhancement in SNP care coordination.
- Lead and conducted Mock audits for SNP care coordination.
- Used excellent verbal skills to engage clients in conversation and effectively determine needs and requirements.
- Conducted market research to identify selling possibilities and evaluate customer needs for potential SNF Mock Audit Program.
Manager- Care Management
Humana Medicare Advantage Plan
09.2016 - 03.2022
- Managed a team of RN case managers responsible for telephonic case management tasks
- Telephonic case manager: employs a variety of strategies, approaches and techniques to manage a member's physical, environmental and psycho-social health issues
- Identifies and resolves barriers that hinder effective care
- Ensures patient is progressing towards desired outcomes by continuously monitoring patient care through assessments and/or evaluations
- Create member care plans and follow up on any care gaps identified
- Act as a subject matter expert (SME) to new hires and team members
Team Lead Medicare Part D
Blue Cross & Blue Shield of North Carolina Medicare Advantage Plan
09.2013 - 07.2016
- Part D Team Leader, managed day-to-day business area activities, provided leadership/direction to team members, set expectations for individual contributors
- Acted as a technical resource for team members providing assistance/guidance on system issues, benefits, and work processes and procedures
- Created a positive work environment that fostered teamwork, empowerment, accountability, and ownership was also a part of my role
- Developed work processes, quality improvements, goal setting, and decision-making
- Acted, to guide and motivate others to support and reflect the core competencies of BCBSNC
- Identified trends, and performed root cause analysis, and initiated appropriate action to resolve issues
- Designed, developed, and implemented tools and techniques for improvement and promote change efforts of the organization within the team
- Provided input and worked with organization leadership in the development of budgets and goals and the management of compliance at the team level
- Ensured goal alignment among teams
- Facilitated meetings and conducts formal presentations as needed
- Acted as a medical resource for team members and other departments, providing assistance and guidance on medical necessity, bundling inpatient admissions, pre-existing and pricing issues
- Served as liaison between Medical Review and the Medical Directors supporting the department
- Worked closely with Compliance to ensure that all functions including medical necessity reviews and determinations met all requirements imposed by regulatory agencies such as NCDOI, NCQA, BCBSA, Federal, etc
Director of Health Services
Fidelis Secure Care of North Carolina
03.2006 - 09.2013
- Lead North Carolina market executives to achieve membership growth targets, profitability goals, and reduce Medical Loss Ratio (MLR)
- Developed membership targets for each Skilled Nursing Facility (SNF) contracted with the Plan
- Review MLR, APK, IP/OP cost with Medical Director and Plan executives monthly
- Created action plans to address gaps identified in MLR, APK, IP/OP cost review
- Develop and presented Plan Quality Metrics with internal senior leadership team at quarterly meetings
- Conducted market analysis to assess network adequacy
- Conducted a membership growth market analysis to evaluate growth potential and develop strategies to meet Plan membership goals
- Created action plans to sustain growth and profitability
RN Field Care Manager
Fidelis Secure Care of North Carolina
03.2005 - 03.2006
- Complete an initial member assessment on all new enrolled members, including a medical record review where available
- Perform ongoing assessments commensurate with member risk level and/or identified need
- Development of a plan of care to establish a collaborative approach to member needs across clinicians and care delivery
- Initiate and maintain ongoing communications with the interdisciplinary care team (ICT)
- Meet with families/responsible parties for collaboration on member plan of care and discussion of member/family/responsible party contribution to the ongoing management of member condition
- Coordinate care across the continuum of care delivery model as the point of contact for member/caregiver and clinicians
- Act as liaison between providers, nursing facilities, hospitals and Fidelis staff, including making recommendations about care alternatives or equipment that will aide in the safety of the member while promoting optimal clinical outcomes
- Monitor member progress to plan of care goals with emphasis on member care need during transitions and changes in member level of care needs
- Provide nursing/assisted living facility and provider education on Fidelis Secure Care philosophy and Model of Care (MOC)
- Main educator for members and/or families/responsible parties on disease processes and ways to manage disease progression as independently as possible
- Serve as a resource to the entire care delivery team
Nursing Home Administrator
Baptist Retirement Homes
08.2004 - 03.2005
- Developed and implemented policies and procedures for nursing home operations.
- Conducted interviews of potential employees to ensure quality care was provided by staff members.
- Monitored budgeting, revenue and expenditure reports to maintain fiscal responsibility in the organization.
- Supervised all administrative staff, including nurses, therapists, aides and other personnel.
- Ensured compliance with state and federal regulations regarding patient care standards and safety protocols.
- Analyzed data from surveys to evaluate the effectiveness of services provided within the nursing home environment.
- Provided leadership in developing long-term strategies for meeting organizational goals related to patient care outcomes.
- Collaborated with medical directors to develop clinical policies that would improve patient care processes within the facility.
- Negotiated contracts with third-party vendors who supplied goods or services used in providing patient care.
- Worked closely with legal counsel on matters related to liability insurance coverage, employee benefits packages, labor laws.
- Reviewed applications from prospective residents prior to admission into the nursing home facility.
- Managed daily operations of the nursing home including staffing schedules, medication administration records, food service management and financial record keeping.
Director of Nursing
Kindred Healthcare
03.2003 - 08.2004
- Developed and implemented nursing policies, procedures, and protocols to ensure patient safety.
- Provided clinical guidance and direction to nursing staff to ensure quality care was provided in a timely manner.
- Oversaw the daily operations of the nursing department including staffing, scheduling, budgeting, and resource allocation.
- Conducted performance evaluations for all nursing staff members and made recommendations for improvement when necessary.
- Ensured compliance with state regulations regarding nurse-to-patient ratios and other safety guidelines.
- Collaborated with physicians and other healthcare providers to coordinate patient care plans.
- Implemented strategies for improving patient satisfaction scores in the nursing department on an ongoing basis.
- Monitored changes in laws and regulations related to healthcare delivery services to ensure compliance with all applicable standards.
- Created reports summarizing patient outcomes based on data collected from various sources.
- Attended meetings with senior management personnel to provide updates on progress of projects and initiatives being undertaken by the nursing team.
- Facilitated communication between departments within the hospital setting to improve efficiency.
- Reviewed incident reports submitted by nurses related to any adverse events that occurred during their shift.
- Advised physicians on best practices related to prescribing medications or treatments for patients under their care.
- Developed and maintained staffing schedule in accordance with contract terms, budget mandates and accreditation standards for nursing coverage.
- Implemented changes needed to correct deficiencies found during government inspections.
- Coordinated medical and health services in compliance with government regulations and policies set by board of trustees.
Education
Baccalaureate of Science - Nursing
06.2019
Certified Case Manager -
01.2013
Nurse Management Institute -
for Long Term Care Managers
01.2005
Nursing Home Administrator License -
01.2003
Associate Degree -
in Nursing-RN
08.1990
Licensed Practical Nurse-LPN -
11.1987
Skills
- Quality Service Delivery
- Proposal Strategy
- Evidence-Based Business Analysis
- Strategic Creative Thinking
- Collaborative Problem-Solving
- Client Engagement Support
- Program follow-up and assessment
- Detail-Oriented Approach
- Workflow Streamlining
- Quality Assurance Evaluation
- Advanced Computer Proficiency
- Performance Metrics Development
- Quality Management
- Excellent communication
- Cross-Functional Collaboration
- Documentation and reporting
Certification
- Certified Case Manager (CCM)
References
Available upon request
Work Availability
monday
tuesday
wednesday
thursday
friday
saturday
sunday
morning
afternoon
evening
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Work Preference
Work Type
Full TimeWork Location
RemoteHybridImportant To Me
Career advancementWork-life balanceFlexible work hoursHealthcare benefitsWork from home option401k matchPaid time offStock Options / Equity / Profit SharingPaid sick leaveQuote
The ones who are crazy enough to think they can change the world, are the ones that do.
Steve Jobs
Languages
English
Native language
Timeline
Senior Health Plan Services Consultant
BluePeak Advisors
03.2023 - Current
Manager- Care Management
Humana Medicare Advantage Plan
09.2016 - 03.2022
Team Lead Medicare Part D
Blue Cross & Blue Shield of North Carolina Medicare Advantage Plan
09.2013 - 07.2016
Director of Health Services
Fidelis Secure Care of North Carolina
03.2006 - 09.2013
RN Field Care Manager
Fidelis Secure Care of North Carolina
03.2005 - 03.2006
Nursing Home Administrator
Baptist Retirement Homes
08.2004 - 03.2005
Director of Nursing
Kindred Healthcare
03.2003 - 08.2004
Baccalaureate of Science - Nursing
Certified Case Manager -
Nurse Management Institute -
for Long Term Care Managers
Nursing Home Administrator License -
Associate Degree -
in Nursing-RN
Licensed Practical Nurse-LPN -
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