Theonna Johnson
Cedar Hill,TX
Summary
Seeking a full-time opportunity to leverage 20+ years of experience in the medical management industry. Offering extensive years of experience in delivering effectiveness including collaborating with facilities and other treatment providers to ensure consumers are treated in a clinically appropriate level of care. Consistently working in dynamic and challenging environments; accustomed to collaborating with the team to achieve common goals. Promote open interactive communications throughout the organization in an effort, to gain understanding of all business processes and increase current knowledge skill set. Thrive in developing effective resolutions, identifying issues, driving new initiatives, evaluating trends and risks. Possess good intellectual and interpersonal skills as evident through handling increasing job assignments and responsibilities. Exhibits outstanding technical acumen, which include MS Word and Excel, Lotus Notes, EAA, Aerial and ECM, Tableau, Facets, Microsoft Teams and Zoom.
Overview
22
22
years of professional experience
Work History
Senior Quality Improvement Coordinator
Blue Cross Blue Shield of KC
03.2023 - Current
- Developed and established quality committees. This includes creating and implementing PowerPoint presentation slides, for business owners to present all reporting deliverables
- Schedule quality committee meeting for CSC, NME, NCQA Oversight, including new development of Quality Oversight committee, to review effectiveness of performance mitigating risk, improving throughput and achieving customer satisfaction
- Establish and created annual quality work plan of all quality annual activities to meet compliance of standards
- Apply knowledge of NCQA health plan standards to make insightful observations of possible high-risk, trends and successes.
- Developed and presented annual NCQA 2024 training for all stakeholders, with intent to educate and provide improved understanding of quality standards and best practices.
- Establish a culture of continuous improvement, fostering proactive problem-solving among team members and business owners
- Assess ongoing operations via annual reporting documents against NCQA standards by reviewing timely reporting to ensure Accreditation compliance is met
- Successful ACA submission in October 2023, with the UM standard chapter scoring high
- Facilitated open communication channels between utilization management teams via implementation of new small group meetings to bridge gaps in understanding related to quality accreditation expectations.
- Readily available to assist manger and team mates with providing guidance as needed, particularly regarding quality committees, transcribing meeting minutes by creating templates
Accreditation Consultant
Elevance Health
06.2022 - 03.2023
- Responsible for creating yearly Quality Committee scheduler for all Health Plan committees, providing all Business Owners with a timely schedule of all NCQA deliverable due dates
- Facilitate all Quality Committees, including sending out all meeting invites, creating all meeting agendas to all Business Owners, to ensure all State contractual and NCQA reports are approved timely for MAC (Medical Advisory Committee), CSC (Clinical Service Committee), SQC (Service Quality committee), and the overarching QMC (Quality Management Committee) for final approval. Upon the conclusion of all QMC meetings, transcribe meetings minutes, and send to Plan MD for signature
- Facilitate and schedule all Kick-off meetings with key stakeholders, providing NCQA standards education and assistance in completing all NCQA reports
- Facilitate RCA sessions (Root cause analysis) with business owners to identify trends and review annual HEDIS and CAHPs results, identify barriers and opportunities for improvement moving forward and educate staff on how to incorporate results into the annual NCQA reports
- After completion of all RCAs, complete all annual NCQA quantitative analysis and results/outcome in the annual reporting template; meet with business owners to identify reporting template and remaining sections of the template, that need to be completed by the business owners including deliverable deadlines, to ensure QMC and other sub-committee approval
- Prepare all UM Denial and Appeal file reviews by bookmarking and annotating, for virtual accreditations surveys
- Assist and complete dry-run review with UM staff, to provide guidance for virtual file reviews to ensure a seamless virtual survey
- Monitor staff performance regarding federal, corporate and accreditation standards and guidelines.
- Participate in quality initiatives and manage department initiatives related to NCQA file review audits and non-file evidence
- Provide ongoing guidance/ training of NCQA standards to business owners as needed
- Liaised with business owners and upper management, to better understand quality & accreditation needs and recommend appropriate solutions.
Behavioral Health Sr. Accreditation Consultant
Blue Cross Blue Shield of Texas
01.2017 - 05.2022
- Prepare all BH UM, CM denial and Appeal file reviews by bookmarking and annotating, for onsite accreditations surveys
- Monitor staff performance regarding federal/state contractual and accreditation standards and guidelines.
- Participate in quality initiatives and manage department initiatives related to Department of Insurance NCQA and URAC audits.
- Overnight business travel to successfully prepare all Behavioral Health evidence including file reviews to present to both NCQA and URAC entities to complete 3-year continual accreditation.
- Evaluate and recommend action on high profile inquiries from Legal Department, Office of the Attorney General, Health Care Bureau, Department of Insurance, and the Executive Inquiry Department.
- Serve as liaison with internal/external departments, employer groups, regulatory agencies, accreditation agencies, and legislative entities.
- Successfully submitted the renewal for NCQA TX ON Exchange and URAC.
- Received recognition from the Sr. Medical Director for case preparation and documentation.
- Recognized as a Subject Matter Expert for BCBS TX BH New Mexico, Marketplace, FEP, IL Commercial Appeals.
- Achieved Quality and Accreditation at 100% score for NCQA Onsite audit in 2018 - 2021.
- During the 2020 Accreditation preparation season, implemented new a SOP that resulted in 1.1 million cost savings for additional use of external consultants
- Trained all new staff virtually via WebEx meetings during 2020, to ensure on going Accreditation compliance during COVID-19 pandemic
- Project management of multiple Accreditation and Quality Management deliverables
- Implemented strong analytical skills to identify trends and patterns in quality data related to accreditation performance.
Behavioral Health Appeal Analyst
Blue Cross Blue Shield of Texas
01.2015 - 01.2017
- Complete all medical necessity Appeal denial and approval letters, including additional member appeal rights and provide member education on how to submit appeal requests
- Respond to member phone calls and to mailed written appeal requests correspondences, by providing member guidance for additional member appeal rights
- Maintain and remain knowledgeable with all appropriate State and Federal DOI mandates required to ensure all appeals, IRO and custom group commercial plans are completed within timely guidelines while ensuring reaccreditation for NCQA TX ON Exchange and URAC as well as all other BH lines of business
- Interpreted insurance regulations, state and federal laws, and company policies to determine the validity of appeal request upon receipt.
- Conducted workplace compliance training to reduce liability risks and operate effectively.
- Generated annual file review list reports detailing findings and recommendations, to determine trends and mitigate risks, to ensure health cost savings.
Behavioral Health Coordinator
Blue Cross Blue Shield of Texas
01.2013 - 01.2015
- Complete monthly department audits for BH Unit Manager
- Facilitate and schedule all internal and external BH Providers peer to peer reviews, for Utilization Management medical necessity requests
- Send out all member UM denial letters via the mailing system timely and respond to all member and provider BH peer review requests via phone call
- Improved patient satisfaction scores by providing compassionate, person-centered care and support to individuals and families, upon notification of denial by advocating for member appeal, as next course of action
- Maintained accurate documentation of client progress, assessments, interventions, and discharge planning in electronic health records system via EAA (Enterprise Appeals Application)
- Mentored via new Behavioral Health Coordinators employee training by sharing best practices inpatient care coordination and case management processes
- Annually reviewed and updated as needed policies and procedures, maintaining compliance with guidelines relating to HIPAA, URAC and NCQA standards
Disease Management Utilization Inquiry advocate
Blue Cross Blue Shield of Texas
01.2009 - 01.2013
- Provide member education of available DME, prescription and provider benefits
- Ensure all member requests for DME and additional member benefit correspondences are generated via the mailing system to members timely
Billing Specialist Consultant
Trinity Hospice
01.2007 - 11.2008
- Researched and resolved hospice Medicare billing discrepancies to enable accurate billing.
- Identified, researched, and resolved billing variances to maintain system accuracy and currency.
- Assisted colleagues in resolving complex billing issues, promoting teamwork and knowledge sharing within the department.
Billing Specialist Consultant
Pinnacle Partners in Medicine
01.2006 - 01.2007
- Researched and resolved pain management office billing discrepancies to enable accurate billing.
- Identified, researched, and resolved billing variances to maintain system accuracy and currency.
- Worked with multiple departments to check proper billing information.
Medical Office Billing & Appointment Associate
Dallas Diagnostic Association
01.2003 - 01.2006
- Increased customer satisfaction by resolving complex issues and providing exceptional service at all times.
- Managed high-stress situations effectively, maintaining professionalism under pressure while resolving disputes or conflicts.
- Handled escalated calls efficiently, finding satisfactory resolutions for both customers and the company alike.
- Ensured compliance with HIPAA regulations when handling sensitive patient information, protecting client privacy at all times.
- Managed difficult conversations with compassion and professionalism, helping deescalate tense situations while maintaining a focus on finding resolutions.
- Maintained accurate records of customer interactions, ensuring proper documentation within the company''s database.
- Expedited service times with effective triage of incoming calls, directing patients to the correct department or resource.
- Educated patients on importance of preventive health care and insurance coverage.
- Resolved patient billing issues in line with established guidelines.
Education
Training HIPPA/OSHA -
Baylor Health Care System
01.2004
Continuing Education -
Dallas Community College
01.2003
General Diploma -
Lakeview Centennial High School
01.2001
Skills
- Knowledgeable of Appeal Processes, Action Plans and Analysis Insurance Verification
- Health Plan organization URAC & NCQA accreditation subject matter expert
- Problem Resolution and Decision Making
- Medical Records (HIPPA Compliant), Data Entry 75 WPM Continuous Process Improvement
- Use Windows PC, Macintosh, Lotus, MS Word, Excel, Lotus Notes, EAA and ECM and Tableau and other specialized programs
- Strong interpersonal skills and consistently working in dynamic and challenging professional environment; accustomed to collaborating with peers to achieve common professional goals
- Relationship building, while providing excellent customer service with internal and external associates
References
References available upon request.
Timeline
Senior Quality Improvement Coordinator
Blue Cross Blue Shield of KC
03.2023 - Current
Accreditation Consultant
Elevance Health
06.2022 - 03.2023
Behavioral Health Sr. Accreditation Consultant
Blue Cross Blue Shield of Texas
01.2017 - 05.2022
Behavioral Health Appeal Analyst
Blue Cross Blue Shield of Texas
01.2015 - 01.2017
Behavioral Health Coordinator
Blue Cross Blue Shield of Texas
01.2013 - 01.2015
Disease Management Utilization Inquiry advocate
Blue Cross Blue Shield of Texas
01.2009 - 01.2013
Billing Specialist Consultant
Trinity Hospice
01.2007 - 11.2008
Billing Specialist Consultant
Pinnacle Partners in Medicine
01.2006 - 01.2007
Medical Office Billing & Appointment Associate
Dallas Diagnostic Association
01.2003 - 01.2006
Training HIPPA/OSHA -
Baylor Health Care System
Continuing Education -
Dallas Community College
General Diploma -
Lakeview Centennial High School
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