Tomanica L. Williams
Suffolk,Virginia
Summary
Dedicated and compassionate registered nurse leader with 24 years of extensive experience in various healthcare settings. Proficient in Managed Care Organizations (MCO) and quality improvement, excelling in auditing according to NCQA guidelines and motivating teams to achieve a 3-year Health Plan Accreditation. Demonstrates critical thinking skills and a proven track record in enhancing team performance and healthcare standards.
Overview
24
24
years of professional experience
1
1
Certification
Work History
Team Coordinator, Quality Services
Sentara Health Plans
04.2023 - Current
- As Team Coordinator, I assume responsibility, and accountability, provide leadership for daily operations, coordinate work, quality, and service, and supervise team members in assigned areas
- Managed the daily operations of a brand-new start-up team of Quality Improvement Coordinators for Managed Behavior Health Organization (MBHO) and Health Equity Accreditation (HEA)
- Facilitates staff management in a multi-skilled, multi-functional environment and coordinates quality improvement activities, resolution of customer service issues, and management/monitoring of resource utilization
- Improved team collaboration with regular meetings, 1:1 with staff monthly, progress updates, and transparent communication.
- Provide project management and facilitation, as well as clinical oversight and support for developing, coordinating, implementing, and evaluating quality improvement and patient safety initiatives
- Provide consultation and education within the division and across the System in Performance Improvement and/or Peer Review
- Assisted in maintaining liaison with external agencies in quality, peer review, and accreditation surveys/inspections
- Acts as a subject matter expert and provides education/guidance to direct the development of compliant processes, projects, and monitoring performance on accreditation standards to primary business owners
- Review clinical policies & procedures in accordance with applicable regulatory and accreditation standards (e.g., NCQA)
- Prepared for National Committee for Quality Assurance (NCQA) final submission documents validating quality and accuracy including content compliance with accreditation and annotating and bookmarking standards
- Uploading documents to NCQA IRT portal for survey
- Participated in the 2024 NCQA survey for MBHO and HEA Accreditation. Sentara Health Plans received 3-year accreditation for MBHO and HEA.
Quality Assurance Auditor, Case Management
Evolent Health
05.2022 - 01.2023
- Accountable for managing the quality review process for care management programs
- Accountable for review of clinical documentation and if available, staff phone recordings against program descriptions, workflows, and internal policies in alignment with evidence-based clinical guidelines, NCQA guidelines, CMS guidelines and regulatory guidelines (when applicable)
- Audit Care Management documentation of CM staff’s case interventions, completion of phone calls and actions, interventions applicable to meeting goals of Care Management program
- Generated monthly Care Management Quality reports on staff performance to submit to the Clinical Operations Manager
- Provide analysis of data to drive scorecards, action plans, and continuous improvement of programs, in addition to program delivery and outcomes
- Provided written feedback to managers and supervisors concerning quality concerns on individual performance, compliance risks/trends, root cause analysis, and any system or process improvements recommended
- Participated in NCQA Committee meetings for Care Management, Care Management Committee monthly meetings, and any other meetings assigned
- Assisted in file prep and review for NCQA CM and Population Health audits for August 2022
- Evolent received 3-year accreditation
Clinical Quality Auditor (Complex and Behavioral Health)
Elevance
09.2015 - 01.2021
- Ensures each review/audit is supported by clinical citations and references when applicable and follows policies and procedures according to company, health plan specific, and NCQA standards
- Conducted internal monthly audits for new and existing health plans (Medicare and Medicaid) for the following areas: Complex and Behavioral Health Case Management
- Assist with creating supporting clinical auditing tools for internal audits for complex and behavioral health
- Evaluation of clinical information, including medical records and phone review, for multiple health plans
- Ensures all client instructions and specifications have been followed and all questions addressed according to NCQA policy and procedures
- Identifies any inconsistencies within the records and contacts Peer Review to obtain clarification, modification, and correction as needed
- Attend meetings with health plan managers as a Subject Matter Expert (SME) to discuss audit results and give feedback to health plan managers to ensure improvement in auditing scores of case managers
Nurse Case Manager II (Complex and Behavioral Health CM)
Amerigroup/Anthem
06.2013 - 09.2015
- Responsible for performing care management telephonically within the scope of licensure for members with complex, chronic, and behavioral health care needs by assessing developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum
- Use appropriate screening criteria knowledge and clinical judgment to assess member needs via outbound phone calls to members
- Conducts assessments to identify individual needs and develops care plan to address objectives and goals as identified during assessment
- Coordinates with internal and external resources to meet identified needs of the members and collaborates with providers
- Interfaces with Medical Directors and Physician Advisor's on the development of care management treatment plans
- Working from phone queue, takes inbound phone calls from members returning case management outreach calls
- Maintain caseload of 65+/month per metric standards
- Act as a Subject Matter Expert based on disease management areas of expertise: facilitate ongoing staff training, provide information regarding medications updates and continued education
Team Lead PACT Psychiatric Field Nurse
Chesapeake Integrated Behavioral Healthcare (CIBH)
06.2009 - 06.2013
- Program of Assertive community treatment (PACT) for individuals with serious mental illness who need ongoing, drop-in services to enable them to live successfully in their community, thus minimizing their need for continued psychiatric hospitalization
- Assist in supervision of RN’s and LPNs with program supervisor
- Conduct and carry out nursing staff meetings, coordinate daily medical schedule
- Audit nursing eMAR and documentation
- Assist the PACT’s Supervisor in performing human resource functions such as interviewing, selection recommendations, employee performance reviews and disciplinary action
- Adhere to regulatory bodies and licensing rules of DMAS (Department of Medical Assistance Services), guidelines, and all established protocol to carry out all duties required by contract, licensure, accreditation, and certification relative to program or service assignment
- Daily field visits to assess mental status, administer medication and psychotropic injections per Psychiatrist
- Prepare daily and weekly pill packs for consumers as directed by physician
- Take medications to consumer and observe them take medications daily
Staff Nurse, Outpatient Surgery Unit
Sentara Bayside
10.2005 - 11.2008
- Provide pre-operatively nursing care to outpatient surgical patient population
- This included: orthopedic, gynecological, breast, vascular, endoscopy, and general surgery
- Demonstrate flexibility, and adaptability to changes in nursing practices, surgical procedures, and case volumes
- Exercise safe judgment in decision making and medication administration
- Served as Charge Nurse and maintained effective working relationships with interdisciplinary teams
- Communicated pertinent information to OR, PASS, and PACU Team Leaders
- Available for on call emergency case calls as assigned
Staff Nurse, Endoscopy Prep & Recovery
Sentara Norfolk
11.2003 - 10.2005
- Prepped and recovered patient population for following procedures: EGD, Colonoscopy, Bronchoscopy, Sigmoidoscopy, Peg Tube insertions and ERCP’s
- Deliver a complete range of RN services and expertise
- Accurately obtained and documented patient history and medication lists, assessed individual conditions, and needs
Cardiac Step-down Nurse
Sentara Norfolk
12.2000 - 11.2003
- Provided care for the following Cardiac Step-down patients: post-operative open heart, transplant patients (heart & lung), thoracic procedures, post intervention, Acute Myocardial Infarction, and Congestive Heart Failure
Education
Bachelor of Science - Nursing
South University
12-2012
Associate of Applied Science - Nursing
Tidewater Community College
05-2000
Skills
- Auditing (NCQA Guidelines)
- Managed Care (Medicaid & Medicare)
- Field/Telephonic Case Management
- Team motivation
- Team-building activities
- Electronic Medical Records
- Critical Thinking
- Behavioral Health
- Motivational Interviewing
- Teamwork and Collaboration
Certification
Registered Nurse (RN), Virginia Compact (Active)
Proficiencies
NCQA Guidelines, Medicaid & Medicare, Case Management, Behavioral Health, Microsoft Office Suite, Trained Super User for various electronic medical records
References
Available Upon Request
Timeline
Team Coordinator, Quality Services
Sentara Health Plans
04.2023 - Current
Quality Assurance Auditor, Case Management
Evolent Health
05.2022 - 01.2023
Clinical Quality Auditor (Complex and Behavioral Health)
Elevance
09.2015 - 01.2021
Nurse Case Manager II (Complex and Behavioral Health CM)
Amerigroup/Anthem
06.2013 - 09.2015
Team Lead PACT Psychiatric Field Nurse
Chesapeake Integrated Behavioral Healthcare (CIBH)
06.2009 - 06.2013
Staff Nurse, Outpatient Surgery Unit
Sentara Bayside
10.2005 - 11.2008
Staff Nurse, Endoscopy Prep & Recovery
Sentara Norfolk
11.2003 - 10.2005
Cardiac Step-down Nurse
Sentara Norfolk
12.2000 - 11.2003
Registered Nurse (RN), Virginia Compact (Active)
Bachelor of Science - Nursing
South University
Associate of Applied Science - Nursing
Tidewater Community College
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