Shawn Marie Cooperrider

Leads activities in analyzing physician and hospital performance results and directs the implementation of clinical initiatives to drive improved outcomes

and close performance gaps.

Leads the establishment of new and ongoing relationships with key physician groups and hospitals to drive improved clinical outcomes, working with Market Medical Executives, Health Experience Leads, and Contracting Leads.

Influences, and leads projects and functions that drive innovation, initiatives, and interventions to improve clinical quality processes and outcomes.

Drives clinical outcomes as measured through the annual Healthcare Effectiveness Data and Information Set (HEDIS) project, manages temporary HEDIS staff and /or individuals assigned to the project and effectively engages providers and vendors to successfully complete the project within the organizational timeframe.

Authors and presents HEDIS Executive Summary and Quality Management Plan Evaluation to Cigna Clinical Advisory Committee meetings.

Assisted with the Development and Implementation of the Ohio Medicare Medicaid Plan (MMP) and Medicaid Care Manager Audits to provide insight into the accuracy of the health plan care coordination processes and assess adherence to contractual requirements.

Work with business and data analysts to streamline Community Care Reports to easily identify completed monthly visits.

Implemented an analysis to identify trends in overall audit results per month and quarter.

Developed tracking logs to provide streamlined consistent notification on nurse audit performance to managers, Vice President, and directors.

Coordinates with claims, member services, grievance coordinator, and other operational departments regarding case management issues.

Conducts utilization management reviews for inpatient, outpatient, or skilled nursing cases.

Documents and communicates to QM staff appropriately all identified quality concerns related to members.

Process Medicare denials according to Medicare Guidelines within specified time frames.

Identify best practices that improve the quality of care within Medicare compliance guidelines.

Collaborate with various matrix partners in the Mt. Carmel system (case managers, physicians, etc.)

Provide resources to Medicare Advantage members on Medicaid Waiver programs, various financial programs, prescription assistance and local programs.

Reviewed Quality of Care Complaints (QOC) and Adverse Events following state and federal mandates; presented cases to Cigna Medical Director and Peer Review Physician Panel and developed Corrective Action Plans with hospitals and physicians, if indicated.

Level II Member Appeals Committee Participant.

Assist with Clinical Initiatives on various disease management programs including the Robert Wood Johnson Cigna Research Study on Hypertension.

Assisted with Evidence-Based Medicine (EBM) Audits and Cigna Quality of Care Designation for physicians.

HEDIS Market Lead responsible for medical record collection for two markets, OH and PA.

Assisted with National Appeals Oversight Audits.

Research co-lead on National Health Disparities Group.

Responsible for writing and analyzing the quality performance of the western region of Cigna and presentation to the National Quality Committee.

Led various work groups during HEDIS off-season to analyze barriers, improve medical record collection, and improve health plan ratings for the upcoming year.

Interviewed, hired, trained, and managed temporary nurses and administrative staff during HEDIS season.

Reviewed and audited hospital bills over $75,000 utilizing customer contracts and standard billing practices.

Lead on provider appeals for hospital bill audits.

Reviewed prospective and retrospective authorizations and appeals for surgery and inpatient stays utilizing customer benefits, and state and federal compliance guidelines.

Implemented Cigna Wellness Program for onsite employees in collaboration with nurse team; offered cholesterol and wellness screenings.

Worked with Cigna Fraud unit reviewing and referring possible fraud cases.

Performed prior authorization review of services requiring notification.

Submitted cases for criteria failures and helped facilitate resolutions and approvals.

Evaluated medical guidelines and benefit coverage to determine the appropriateness of services.

Audited hospital bills and collaborated with stop loss (reinsurance) carriers to identify potential catastrophic cases.

Participated in sales meetings with prospective/current employer groups to answer medical coverage questions.

Developed infusion therapy policies and procedures for a home infusion company.

Obtained orthotic and prosthetic certification and did diabetic teaching on home blood glucose monitors.

Assisted private insurance, Medicare, and Medicaid customers to obtain durable medical equipment, fitted braces, surgical-grade compression stockings, and external breast prostheses.

Worked with Medicare and Medicaid guidelines obtaining prior authorizations, educating customers on their coverage, and requesting medical documentation from their physicians for billing.

Supervised home healthcare technicians.

Provided supportive care to chemically dependent individuals.

Observed patients for signs and symptoms of alcohol and drug withdrawal and collaborated with various disciplines for coordination of care.

Trained new nurses in proper techniques, care standards, operational procedures, and safety protocols.

Coordinated nursing care on the unit through staff assignments, assisting and rounding with physicians, monitoring patient orders, and communicating with ancillary departments.

Conducted daily shift briefs to inform staff of changes in patient care assignments.

Supervised and managed daily scheduling, tasking, and administration.

Performed various nursing interventions such as wound dressing, vital sign monitoring, and specimen collection.

Administered medications via oral, IV, and intramuscular injections and monitored responses.

Assessed physical, psychological, physiologic, and cognitive status of patients.

Monitored patients' conditions and reported changes in physical presentation, appearance, and behavior to discuss treatment with physicians.

Updated patient charts with data such as medications to keep records current and support accurate treatments.

Implemented medication and IV administration, catheter insertion, and airway management.

Collaborated with physicians, pharmacists, and therapists to deliver quality, evidence-based care.

Answered call lights and supported patient comfort and safety by adjusting bed rails and equipment.

Helped patients effectively manage routine bathing, grooming, and other hygiene needs.

Cared for residents in nursing facilities and delivered high-quality support to meet needs.

Monitored, tracked, and conveyed important patient information to healthcare staff to help optimize treatment planning and care delivery.

Maximized patient satisfaction by helping individuals carry out personal tasks such as dressing and walking.

Provided patients with personal hygiene assistance by giving bedpans, baths, and backrubs and assisting with travel to the bathroom.