Shannon Smith, RN
Managed Care Professional
Rio Rancho,NM
Summary
Accomplished Executive Director recognized for leveraging strong team leadership and development to drive forward progress. Highly organized, detail-oriented leader skilled in directing high-performing teams to develop solutions and solve operational and technical problems. Success implementing systems across multiple operations with superior organizational and communication skills.
Overview
11
11
years of professional experience
1
1
Certification
Work History
Executive Director of Delegation and Clinical Support Services
Presbyterian Health Plan
02.2024 - Current
- Managed a team of 200 employees with an Annual Operating Budget of 10 million dollars.
- Oversaw financial management, ensuring fiscal responsibility and long-term sustainability for the organization.
- Identified cost savings of 7 million dollars due to reconciliation and/or recoupment of claims/encounter processing errors.
- Utilized Digital Technology solutions to include the use of Artificial Intelligence, programmed bots and automation to improve workflows and eliminate administrative functions.
- Partnered with external key stakeholders including: New Mexico Human Services Department, Vendors, Community Based Organizations, Hospital/Facility administration, Children, Youth and Families Department, Adult Protective Services, and Providers.
- Drove Strategic and Process Improvements for Population Health and Clinical care models.
- Negotiated and executed contracts for Value Based Programs for Delegated Care Coordination entities.
- Ensured Compliance with all Operational and Regulatory Reporting while conducting in-depth Data and Analytic review.
- Participated in Internal and External Audits to include CMS, NCQA, and HEDIS activities.
- Collaborated in Utilization Management Program Description, Utilization Management Program Evaluation and Delegation Oversight Charter.
Director of Special Programs
Presbyterian Health Plan
08.2018 - 01.2024
- In-depth understanding of Medicaid, Dual Special Needs Plans (DSNP), and Medicare Advantage programs.
- Maintained compliance with clinical programs in alignment with state, federal guidelines with no sanctions incurred.
- Designed comprehensive training programs for staff members, ensuring consistent performance standards and skill development.
- Participated in New Mexico Medicaid Procurement processes.
- Contributed to NCQA Accreditation including Long Term Services and Supports (LTSS) distinction.
- Collaborated with interdisciplinary teams to include: Claims, Benefit/Provider Configuration, Encounters, Finance.
- Assisted with Acquisition Merger activities of Health Plan Membership and Employees.
- Enhanced workflow processes for system integration and optimization.
- Identified as Business Owner of Clinical Teams to Implement Care Management and Claims Management systems.
- Designed comprehensive training programs for staff members, ensuring consistent performance standards and skill development.
- Evaluated program outcomes and adjusted strategies as needed, contributing to continuous improvement efforts.
- Managed teams of Care Coordination, Utilization Management and Support Brokers of over 200 employees.
Manager of Utilization Management
Presbyterian Health Plan
03.2017 - 07.2018
- Enhanced customer satisfaction by resolving disputes promptly, maintaining open lines of communication, and ensuring high-quality service delivery.
- Developed Clinical Policies and Procedures for Utilization Management to maintain timelines and service level agreements.
- Designed and implemented workflow processes for Utilization Management determinations for Outpatient and Inpatient authorizations in a Community-Based or Institutional setting.
- Established timelines for all authorizations based on Medicaid criteria and guidelines.
- Collaborated with IT/EDI/Data and Analytics team to develop internal dashboards and operational reporting for performance measures.
- Created clinical assessments, tools and resources for employees and interdisciplinary teams.
- Participated in Requests for Proposals (RFP) for vendor contracts.
- Enhanced customer satisfaction by resolving disputes promptly, maintaining open lines of communication, and ensuring high-quality service delivery.
- Supervised team with over 30 employees.
Utilization Reviewer
Presbyterian Health Plan
07.2015 - 02.2017
- Subject Matter Expert in Self-Directed Community Benefits, Agency Based Community Benefits and Inpatient Nursing Facility.
- Provided clinical determinations for Outpatient and Inpatient Prior Authorization requests.
- Supported continuous improvement initiatives by actively participating in team meetings, trainings, and workshops focused on enhancing reviewer skills and processes.
- Sustained high levels of productivity under tight deadlines by efficiently using available resources.
- Assisted with implementing Regulatory and Audit Tools
- Maintained strong attention to detail while reviewing numerous documents daily, ensuring consistent quality and accuracy.
- Reduced turnaround time for reviews by effectively prioritizing tasks and managing deadlines.
- Ensured consistency across multiple review projects by maintaining strict adherence to established protocols and procedures.
Care Review Clinician
Molina Healthcare of New Mexico
10.2013 - 02.2015
- Played a key role in the development and implementation of departmental policies and procedures aimed at maintaining high-quality care standards while adhering to regulatory guidelines within the scope of utilization management activities.
- Conducted clinical evaluations including Level of Care (LOC) determinations and prior authorizations in an inpatient and outpatient setting.
- Knowledgeable in 1915(c) Home and Community Based Services (HCBS) Waiver LOC reviews, Individual Service Plan (ISP) Service and Support Plans (SSP).
- Developed desktop level procedures and training materials
- Participated in process improvement activities
- Participated in case reviews with multidisciplinary teams to discuss complex cases and develop collaborative solutions for individualized care plans.
Education
Associate's Degree of Nursing -
Central New Mexico Community College
12.2012
Skills
- Strategic Planning
- Process Improvement
- Project Management
- Change Management
- Budgeting and financial management
- Effective Communicator/Public Speaker
- Relationship Building
- Compliance and regulations
- Contract Management
- Utilization Management
Certification
Registered Nurse (Compact License)
New Mexico Board of Nursing
License Number: RN-77041
References
Jentry Hinton, MBA, Vice President of Integrated Clinical Operations and Strategy
Presbyterian Health Plan, 951-392-9600
Gray Clarke, M.D., Former Chief Medical Officer (CMO)
Presbyterian Health Plan, 505-401-1526
Timeline
Executive Director of Delegation and Clinical Support Services
Presbyterian Health Plan
02.2024 - Current
Director of Special Programs
Presbyterian Health Plan
08.2018 - 01.2024
Manager of Utilization Management
Presbyterian Health Plan
03.2017 - 07.2018
Utilization Reviewer
Presbyterian Health Plan
07.2015 - 02.2017
Care Review Clinician
Molina Healthcare of New Mexico
10.2013 - 02.2015
Registered Nurse (Compact License)
New Mexico Board of Nursing
License Number: RN-77041
Associate's Degree of Nursing -
Central New Mexico Community College
Similar Profiles
Jentry HintonJentry Hinton
Vice President of Integrated Clinical Operations and Strategy at Presbyterian Health PlanVice President of Integrated Clinical Operations and Strategy at Presbyterian Health Plan
Natalie CimarronNatalie Cimarron
Customer Service Representative at Presbyterian Health PlanCustomer Service Representative at Presbyterian Health Plan
KAREN AGUIRREKAREN AGUIRRE
Sr. Quality Improvement Abstractor at Presbyterian Health PlanSr. Quality Improvement Abstractor at Presbyterian Health Plan