Tiffany Wilson

• Experienced healthcare quality professional specializing in clinical quality outcomes and regulatory compliance. Expert in developing and implementing quality improvement programs, with a focus on NCQA/URAC accreditation standards. Skilled in leading cross-functional teams, managing complex quality initiatives, and driving continuous improvement in healthcare delivery systems.
• CORE COMPETENCIES • Quality Program Development & Implementation • Regulatory Compliance & Accreditation Management • Clinical Quality Outcomes • Healthcare Policy & Guidelines • Performance Metrics & Analytics • Project Management • Cross-functional Team Leadership • Process Improvement • Stakeholder Communication
• EXPERIENCE HIGHLIGHTS • Lead enterprise-wide accreditation preparations and submissions • Develop and maintain comprehensive quality management programs • Manage quality committees and improvement initiatives • Design and implement performance monitoring systems • Provide subject matter expertise on accreditation standards • Coordinate with business partners to ensure regulatory compliance • Lead training and development for quality improvement processes
• CERTIFICATIONS • RN, BSN, MHA

• Leading the design and implementation of comprehensive training programs for clinical and non-clinical healthcare staff. Specializing in adult learning methodologies and healthcare systems education.
  
  Key Responsibilities: • Develop and deliver complex clinical training programs across multiple platforms (virtual, in-person, hybrid) • Create and implement new hire onboarding programs for healthcare services staff • Design data-driven curriculum for care management and utilization management • Partner with department leaders to identify learning needs and solutions • Evaluate training effectiveness and implement continuous improvement strategies • Increased employee retention rates by developing engaging onboarding and orientation processes • Streamlined training process for new hires, accelerating time to productivity.
  
  Areas of Expertise: • Adult Learning Methodologies • Clinical Systems Training • Healthcare Policy & Procedures • Virtual Learning Technologies • Performance Evaluation • Curriculum Development • New Hire Onboarding • Cross-functional Collaboration
  
  Technical Proficiencies: • Learning Management Systems • Virtual Training Platforms • Microsoft Office Suite

Professional Development: • RN, BSN, MHA

Skills: Nursing Education · Nursing · Employee Training · Project Management · Blended Learning

• Leading utilization management initiatives to optimize healthcare outcomes while ensuring cost-effectiveness and quality care delivery. Specialized in prospective, concurrent, and retrospective review processes across multiple states.
• Key Responsibilities & Achievements: • Conduct comprehensive medical necessity reviews using evidence-based criteria and clinical expertise • Collaborate with physician advisors to ensure appropriate care determinations • Facilitate seamless care transitions through interdisciplinary team coordination • Manage complex case reviews across multiple states (WA, OR, ID, UT) • Drive quality improvement initiatives through data analysis and process optimization
• Core Competencies: • Clinical Review & Assessment • Medical Necessity Determination • Care Coordination • Healthcare Policy Compliance • Interdisciplinary Collaboration • Documentation & Reporting • Quality Improvement • Regulatory Compliance
• Technical Skills: • Healthcare Documentation Systems • Microsoft Office Suite • Clinical Care Advance (CCA) • Adobe
• Licensure: • Registered Nurse (RN) - Active licenses in ID (compact state)
• Skills: Nursing · Utilization Review · Healthcare · Quality Control

• Increased operational efficiency by streamlining workflows through process mapping and optimization techniques that yielded measurable results.
• Worked to maximize the quality of health care services ensuring that patients receive the care they need without burdening the health care system with unnecessary procedures, ineffective treatments or overlong hospital stays.
• Facilitated root cause analysis investigations for recurring
• Collaborated with cross-functional teams to develop comprehensive quality management plans, ensuring continuous improvement in operations.
• Managed the documentation system efficiently, maintaining accurate records of all quality-related activities and reports.
• Led internal audits periodically, assessing compliance with regulatory requirements and identifying opportunities for improvement within the organization''s systems.
• Meticulously tracked and analyzed key quality metrics, ensuring that organizational targets were met or exceeded on a consistent basis.
• Championed a culture of continuous improvement within the organization by fostering an open environment where employees felt empowered to suggest ideas for enhancements.

• Facilitated interdisciplinary collaboration between physicians, nurses, case managers, coders, and other relevant stakeholders regarding the appropriate representation of patient severity levels within EHRs.
• Analyzed data from audits to identify areas for improvement in clinical documentation processes, implementing targeted interventions for positive change.
• Expedited accurate clinical documentation completion by promptly responding to queries from healthcare providers and support staff, offering timely guidance and support.
• Reduced risk exposure by promptly addressing any identified discrepancies or inconsistencies within patient records.
• Communicated with physicians, nurses and other caregivers to explain importance of accurate and clear documentation.
• Maintained strong knowledge of medical terminology, diseases and conditions and procedures.
• Collaborated with multidisciplinary teams to develop best practices in clinical documentation, streamlining processes and reducing errors.
• Enhanced patient care by ensuring accurate and complete medical records through timely and efficient documentation practices.
• Contributed to revenue optimization by identifying opportunities for appropriate clinical documentation improvement.
• Promoted patient safety through diligent monitoring of adherence to established protocols within the scope of Clinical Documentation Specialist responsibilities.
• Ensured compliance with regulatory standards and guidelines through meticulous attention to detail in completing clinical documentation tasks.
• Carefully reviewed patient files for clarity on diseases, diagnoses and procedures to determine quality of care.
• Served as a resource for healthcare professionals seeking guidance on various aspects of clinical documentation, fostering effective communication among team members.

• 4.0 GPA
• Relevant Coursework: Organizational Development for Health Care, Leadership in Health Care, Health Care Financial Management, Health Law, Human Resources for Health Care Managers, Health Care Statistics, Health Care Operations and Quality Assessment, Health Policy, Community Health Assessment, Health Information Management and Assessment, Health Care Ethics, Health Care Marketing

• Honoree of Phi Beta Kappa