Amy Kile
Berwick
Summary
Accomplished health care professional with a proven ability to plan, manage and deliver projects. Experience in quality and compliance, inspiring peers, and team members. Recognized leadership skills with demonstrated ability to transfer knowledge and learning. Adept at creating and fostering professional relationships. Team player who enjoys intellectual challenges, opportunities for creativity and the willingness to learn new skills.
Pursuing full-time role that presents professional challenges and leverages interpersonal skills, effective time management, and problem-solving expertise.
Overview
10
10
years of professional experience
1
1
Certification
Work History
Sr Quality and Accreditation Consultant
Capital Blue Cross
06.2023 - 06.2025
- Develop framework for structure and processes focusing on NCQA accreditation.
- Assisted in the development of policies and procedures to ensure compliance with accreditation standards
- Manage projects related to QI and Accreditation
- Research and summarize regulatory requirements
- Streamlined internal processes to enhance team efficiency and improve overall project outcomes.
- Delivered high-quality presentations to stakeholders, effectively communicating project objectives and results.
- Collaborated with teams to define, strategize, and implement quality goals.
- Led cross-functional teams in execution of strategic projects, fostering collaboration and ensuring alignment with corporate goals.
- Devised and implemented processes and procedures to streamline operations.
- Conducted regular reviews of operations and identified areas for improvement.
- Developed effective improvement plans in alignment with goals and specifications.
Accreditation Specialist
Centene
08.2022 - 06.2023
- Ensure Health Plan compliance with NCQA standards and State contract requirements
- Knowledge of NCQA standards and Department of Health contracts
- Demonstrated leadership skills through identifying process improvements and proposed solutions
- Advised business units on best practices as it relates to accreditation standards, enhancing overall alignment with requirements.
- Supported senior leadership in decision-making related to accreditation matters, offering data-driven insights and recommendations.
- Ensured alignment with accreditation standards by reviewing business processes, policies, and SOPs within the organization.
- Ensured alignment with accreditation standards by reviewing course content, instructional methods, and assessment strategies within the organization''s educational offerings.
- Managed complex projects involving multiple departments, coordinating efforts to achieve shared objectives related to accreditation status renewal.
- Collaborated with cross-functional teams to develop action plans for addressing areas of non-compliance identified during internal reviews.
- Promoted a culture of transparency and accountability, presenting accreditation findings to relevant stakeholders in an accessible and user-friendly manner.
- Improved overall compliance by conducting thorough audits and providing constructive feedback to departments.
- Complied and reviewed regulatory and contractual requirements and accreditation standards to enforce standard policies and procedures.
- Reviewed accreditation standards and evaluated compliance, identified challenges and proposed solutions.
- Facilitated successful re-accreditation efforts by collaborating with stakeholders to address areas of improvement identified during reviews.
Quality Compliance Analyst
Ashfield Engage
11.2021 - 08.2022
- Investigate acts of suspected non-compliance and provide stakeholder education to ensure compliance with applicable regulatory guidelines
- Communicate verbally and in writing to various levels within the organization as well as external stakeholders
- Proficient in source checking and data base research
- Demonstrated leadership skills through identifying process improvements and proposed solutions during program launch
- Facilitate training of newly hired analysts
- Maintained up-to-date knowledge of industry regulations, providing expert guidance to pharmacies, prescribers and patients on best practices for compliance management.
- Streamlined internal processes to ensure timely completion of required documentation and adherence to industry standards.
- Implemented corrective actions to address identified non-compliance issues, ensuring continuous process improvement.
- Participated in regular meetings with stakeholders to review progress on quality improvement projects, fostering transparency and collaboration between organization, prescribers and pharmacies.
- Communicated with drug manufacturers about REMS program compliance issues.
- Conducted data review and followed standard practices to find solutions.
Pre-Claim Review Specialist
Selman-Holman & Associates
10.2020 - 11.2021
- Performed review choice demonstration for home health claims to assist in fraud prevention and minimize provider burden
- Demonstrated compliance with legal requirements, standards, policies, and procedures
- Proven analytical skills, attention to detail, prioritization, and time management skills to complete caseload.
- Maintained up-to-date knowledge on industry trends and regulations.
- Reviewed high-priority cases with heightened attention to detail, mitigating potential risks associated with non-compliance issues.
- Enhanced review accuracy by streamlining processes and implementing quality control measures.
- Successfully managed multiple competing priorities, balancing workload and ensuring consistent delivery of high-quality reviews.
- Managed a high volume of reviews within tight deadlines, ensuring timely completion and client satisfaction.
Sr. Clinical Quality Management Analyst
Highmark Health
01.2017 - 10.2020
- Responsible for a seven-county territory, ensuring providers and organizations deliver quality healthcare
- Participate in quality improvement projects and provider/ facility credentialing
- Create reports to summarize findings and provide recommendations for quality improvement
- Identify trends in provider populations
- Facilitate provider education and training on quality measures and risk adjustment
- Demonstrated critical thinking and problem-solving skills
- Excelled in management of multiple projects simultaneously
- Serve as a subject matter expert for a team of Quality Analysts, providing coaching and mentoring for improved performance outcomes.
- Audited provider processes and systems to promote adherence to regulatory requirements and industry best practices.
Site Review Consultant
Inovalon
03.2015 - 12.2016
- Completed data collection and audit completion for various risk adjustment projects
- Proven attention to detail to ensure accurate data collection and completion of risk adjustment audit projects
- Knowledge of risk adjustment coding guidelines
- Demonstrated to work in a highly independent position requiring minimal oversight
- Ability to learn new technical skills
- Managed multiple concurrent projects while adhering to strict deadlines, showcasing exceptional multitasking abilities.
- Reduced project turnaround times through meticulous organization and effective time management.
- Continuously updated personal expertise with emerging regulations, industry trends, and best practices, ensuring up-to-date knowledge in support of clients.
- Maintained database systems to track and analyze operational data.
Education
MBA - Healthcare Administration
Southern New Hampshire University
01.2024
Bachelor's - Psychology
Southern New Hampshire University
01.2022
Licensed Practical Nurse - undefined
Hazleton Area Career Center
01.1995
Skills
- Microsoft Office
- Excel
- PowerPoint
- Analytical thinking
- Strategic planning
- Project leadership
- Project management
- Project implementation
- Best practices implementation
- Subject matter expert
- Verbal and written communication
- Stakeholder engagement
- Relationship building
- Excellent communication
- Teamwork and collaboration
Leadership Activities
- National Society of Leadership and Success
- Berwick Historical Society
Certification
Lean Six Sigma-Yellow Belt
Languages
English
Native or Bilingual
Timeline
Sr Quality and Accreditation Consultant
Capital Blue Cross
06.2023 - 06.2025
Accreditation Specialist
Centene
08.2022 - 06.2023
Quality Compliance Analyst
Ashfield Engage
11.2021 - 08.2022
Pre-Claim Review Specialist
Selman-Holman & Associates
10.2020 - 11.2021
Sr. Clinical Quality Management Analyst
Highmark Health
01.2017 - 10.2020
Site Review Consultant
Inovalon
03.2015 - 12.2016
Licensed Practical Nurse - undefined
Hazleton Area Career Center
MBA - Healthcare Administration
Southern New Hampshire University
Bachelor's - Psychology
Southern New Hampshire University
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