shelley timko 0000 xxxxxx xxxx , xxxx , xxxxx 00000
~ career profile ~
health care administration professional with progressive experience in delegation and quality management. ~ consistently achieve optimal regulatory compliance and quality assurance through innovative process improvement planning, program coordination, and cultivation of strong business relationships. ~ lead legal, network contracting, and regulatory negotiations in contract language to ensure compliance of delegated entities. ~ possess an established track record of accomplishments in accreditation management. ~ achieved excellent status as a model for delegation by ncqa in november 2010 for preparing all delegation requirements and serving as site spokesperson. ~ excellent knowledge of jcaho, urac, aaahc and ncqa standards. ~
~ professional experience ~
universal health care, st. petersburg, fl
delegation oversight/quality management
spearhead delegation oversight strategy for a medicare advantage health plan to fulfill cost control and expansion plans in accordance with ncqa accreditation.
lead process improvements to create and implement a detailed delegation work plan by directing activities required to meet regulatory standards of cms, ahca, ncqa, hedis, and doea and accounting for resource limitations of cross functional operational areas.
serve as subject matter expert and liaison on all delegation related subjects for vendors of vision, behavioral health, dental, dme, hhc, pbm, physician, and facility credentialed groups.
chair and organize quarterly delegation meetings by producing meeting minutes and integration into the organization with a resolution driven and proactive operational approach.
oversee quality of member services, it, enrollment, claims, ancillary contracting, legal, compliance, and regulatory departments.
implement document control and improvement of policies, agreements, amendments, and audit tools of delegates and the organization.
negotiate terms of delegation agreements with business owners to meet organizational needs as well as regulatory requirements.
identify organizational areas of improvement to reach strict goals and accreditation requirements by analyzing reports required by delegation agreement with cross-functional organizational areas.
improve medical management and hedis rates while assessing cost factors to maintain optimal cost control on internal and external constituents.
resolve organizational issues by developing methods to track, trend, and analyze complaints, grievances as well as improve activities of clinical and service issues.
monitor of pre-delegation audit process and make recommendations to quality management steering committee to decide on each delegate s acceptance by the organization.
plan pre-implementation processes for audits through a hands-on review of delegates operational and software systems by identifying required tasks.
collaborate with internal organizational partners as well as delegates to meet strict goals and deadlines.
soft computer consultants, clearwater, fl
05/2004 c 11/2006
ar product management/internal auditor
increased client s a/r efficiency by authoring requirements for medical and clinical billing software to address all types of payor scenarios and cover all required billing elements of medical, regulatory, insurance, and printer capabilities in electronic or paper formats.
resolved technical issues by communicating with clients to ensure software functionality.
achieved maximum profitability by leading training initiatives for client administrators to provide efficient use of software reporting tools such as error reports, high dollar reports, unbilled charge reports, and aging reports.
conducted comprehensive audits of internal procedures according to iso 2000 standards for fda and hippa regulatory requirements.
reviewed and interpreted manuals, procedures, and guidelines for medical billing procedural reference materials.
mentored international coworkers on company guidelines and products by assisting them with language barriers.
additional experience: largo medical diagnostic clinic-billing specialist (08/2003-05/2004); american security services-office manager (06/1991-07/2003); equifax services-supervisor of centralized underwriting medical history department (06/1979-05/1991)
~ education ~
b.s. in human services c university of scranton
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