michele kratz

I am an experienced and passionate clinical operations leader, serving the frailest and most complex populations to improve overall health and reduce the cost of care for over 20 years. I have extensive expertise in Medicare Advantage, SNP and managed Medicaid, and thrive in a culture that embraces questioning the status quo to make a difference.

Career highlights include:
 Improving quality; Stars & HEDIS
 Growing & retaining top talent
 Reducing unnecessary utilization
 Audit readiness; CMS, NCQA
 Maximizing operational efficiency & effectiveness

AxisPoint Health, Westminster, CO                                                          October 2020-Present 

Vice President, Clinical Operations 

Lead delivery of care management and population health for multiple clients, targeting high risk membership for multiple Medicare and Medicaid managed care organizations. 

• Achieved and sustained SLA compliance to 95% or greater by consistently delivering care management and population health services to all clients
• Led implementation of end to end oversight processes to ensure operational effectiveness in collaboration with Clinical Content, Technology, Quality, Compliance, Medical Economics and Business Analytics. 
  • Refined and redefined clinical operations processes, roles, system rules and reporting
  • Revamped care management system upgrade process to minimize disruption and support a smooth implementation
  • Strengthened SNP capabilities to comprehensively add value and be audit-ready by revising SNP MOC and aligning internal audit process
  • Contributed to the development of asthma, high risk obstetrics, aging in place, whole person care, and multi-chronic care management programs
  • Adopted software to adequately address SDoH needs by identifying and accessing localized home & community based services
  • Implemented predictive analytics model to improve targeting most impactable, high risk membership to increase enrollment by over 30% and improve program effectiveness
• Identified and addressed operational efficiency opportunities with Business Excellence, increasing productivity by over 50%
• Evolved multi-channel approach to increase member engagement and improve care plan adherence:
  • Implemented virtual visits to enhance member education and increase care gap closure
  • Revamped IVR and member portal access to increase performed HRAs for Medicaid, Medicare and SNP
  • Expanded the use of texting to increase enrollment and ongoing engagement, increasing care gap closure and care plan adherence 
• Strengthened client relationships, leading to improved NPS to 52
• Grew talent by developing and implementing a professional development plan and recruiting top talent for key operational roles.
  • Revised interview process to identify and hire top talent (STAR)
  • Established Leadership Certification for the front-line management team in collaboration with HR, Quality and Training
  • Reduced attrition by over 30% 
• Contributed to growth plan by creating clinical program proposals, attending sales meetings, and presenting in multiple venues 
• Led development and execution of strategic plans to achieve or surpass organizational goals

Upward Health, Providence, RI                                                          August 2019-October 2020

Vice President of Clinical Services 

Responsible for the development and execution of clinical services to proactively address gaps in care related to social determinants, medical and behavioral conditions by incorporating technology-enabled, integrated care to improve outcomes and reduce costs for Medicare and Medicaid beneficiaries with chronic comorbidities. 

• In collaboration with the CMO, developed and implemented an integrated medical home care model
• Created and launched clinical programs to provide comprehensive and effective care, reducing emergency room and inpatient utilization by 30%
• Implemented the care model in new markets and with new lines of business
• Tailored the existing Medicaid integrated medical home care model for the Medicare population.
• Supported Sales & Marketing by contributing to presentation materials and participating in meetings with prospective managed care partners
• Established departmental budget in collaboration with the CFO for all services and lines of business
• Created and implemented enrollment and capacity plans

Cigna, Philadelphia, PA                                                                               May 2012-August 2019

Vice President of Health Services; April 2015-August 2019

Led Medicare Advantage & SNP Health Services for the Mid-Atlantic Market and Illinois; Utilization Management, Case Management (DSNP, CSNP and ISNP), Pay4Quality (P4Q) and Data Analytics. 

• Reduced admissions and emergency room visits by approximately 30%
• Led market to ensure care management structure and services met program and CMS requirements, providing comprehensive care management and care coordination to the SNP population
• Refreshed Health Services model to strengthen collaboration with Behavioral Health, Pharmacy and Network Operations 
• Implemented Complex Care and Disease Management Programs to improve care coordination and utilization; Behavioral Health, Medical Case Management, Palliative Care, Home Visiting PCP and COPD programs 
• Led implementation of Lumeris, improving outcomes through population health management 
• Aligned Medicare clinical programs with Cigna commercial to co-manage populations 
• Integrated P4Q into Health Services, increasing Star rating by 0.5 Star

Director of Operations; October 2014 – April 2015

Led Business Strategy and Optimization team; responsible for strategic planning, project management and budget planning to meet market objectives. Successfully increased revenue to 65 million, exceeding revenue projections. Promoted in 2015. 

Director of Care Management Strategies; May 2012 – October 2014

Identified and implemented Care Management strategies to improve care coordination and health outcomes for the Medicare population in PA, MD, DC and DE. 

• Reduced 30-day hospital readmissions by 2%
• Mirrored CMS Innovations Grant Bridge Program, a social transitional care program, in partnership with Philadelphia Corporation for the Aging (PCA); first managed care organization in the country to do so
• Developed and implemented Integrated Case Management (ICM) Program, supporting medical and behavioral health care needs of the membership
• Implemented LACE, a predictive tool for risk assessment of hospital readmission, to proactively identify and case manage targeted membership
• Led efforts to be the first managed care organization in Maryland to adopt CRISP (Maryland’s Health Information Exchange), using information to strengthen transitional care planning and Stars/HEDIS, increasing member reach rate by over 10%
• Member of Pennsylvania’s eHealth Partnership Authority’s Clinical Committee; established to create Pennsylvania’s Health Information Exchange
• Implemented the Respiratory Care Program, utilizing DME vendors to manage the COPD population post hospitalization

Kindred Healthcare, Havertown PA                                                      February 2008-May 2012

District Director of Case Management                                                                                               

Oversaw Case Management for nine Long Term Acute Care Hospitals (LTAC) located in Pennsylvania and New Jersey to ensure uniformity and integrity of case management initiatives. Collaborated with management, administration, and the healthcare team to deliver high quality case management services to the population served. 

• Assisted with the development and implementation of interdisciplinary clinical documentation improvement (CDI) and interdisciplinary rounding, including physicians;  improved communication; improved documentation; decreased delays in care; positively impacted key quality indicators; and improved the working relationship amongst the interdisciplinary team. Selected to assist other districts with education and implementation of this initiative
• Decreased Medicare LOS by 3.3 days, increased CMI by 15%, increased Normal Stay Types by 10-20%
• Increased internal case management audit compliance by 25% to maintain 90-98% compliance
• Aligned Case Managers with the physicians, improving the quality of documentation and key outcomes
• Established effective working relationships and reporting mechanisms with physicians, administration, finance, and other outside referral sources to improve case management outcomes

Cooper University Hospital, Camden, NJ                                    September 2005-February 2008

Director of Case Management

Oversaw Case Management for a 365-bed acute care facility, largely serving Charity, Medicaid and Medicare populations. Responsible for the development and implementation of the case management plan to achieve clinical and operational performance improvement goals. Ensured that case management services were delivered in a timely, organized, financially productive and efficient manner. Attained compliance with regulatory and managed care requirements, achieving maximized reimbursement. 

• Implemented a new case management model, integrating Case Management with Social Work in October 2005
• In collaboration with Camden Coalition, developed and implemented a community outreach program for high utilizers of the ED
• Implemented Social Work in the ED Department, resulting in a decrease of social admissions
• Observed a decrease in overall LOS by 0.5 days and a decrease LOS greater than 10 days by 25%
• In collaboration with Performance Improvement, implemented a review workgroup and improved CORE measure performance to reach the top 15th percentile
• Revamped the appeals process, decreasing denials by 10%, increasing appeal overturns by 43%

Elderplan, NY, NY                                          July 2000-September 2005                                                     

Director, Medical Management; August 2001-September 2005

Directed the oversight of care delivered to the frailest Medicare population, focusing on social needs to improve health. Oversaw for the Medical Management Department; Authorization Management, Care Management, and Total Life Caring (Health Risk Assessment), consisting of 70 employees. 

• Replicated Metropolitan Jewish Home Care’s Palliative Care Program to more effectively manage member needs, decreasing admissions by 25%, inpatient length of stay by 36% and emergency room visits by 12%
• Implemented key initiatives, such as predictive modeling software to improve identification of members who may benefit from the extended care benefit, increasing Care Management membership by 17%
• Devised and implemented initiatives to increase Health Risk Assessment (HRA) return rate by 35%, thereby effectively identifying actual and potential needs of the membership
• Implemented initiative to remind members and providers regarding preventative care and wellness
• Worked with leadership to expand the Member to Member (time bank) program, improving member retention rates and perception of wellness and health

Manager, Authorization Management; July 2000-August 2001                                                                             

Managed daily operations for pre-certification, concurrent review, and discharge planning. 

• Implemented new authorization and claims software program (AMISYS); developed policies, procedures and a comprehensive educational program
• Introduced utilization review guidelines per industry standard; InterQual and internally developed criteria to ensure sound and consistent initial determinations for requests for service
• Created and implemented a post-hospitalization PCP appointment program, decreasing readmissions by 3%
• Liaison for out-sourced disease state management program (CKD)
• Promoted to Director, Medical Management in 2001

HealthFirst, NY, NY                                                                                         May 1998-July 2000

Manager, Disease Case Management

Responsible for daily operations of asthma/COPD, high-risk obstetrics, and HIV case management programs.

• In collaboration with NYC hospitals, developed and conducted educational sessions for members and their families
• Participated in the New York City Asthma Initiative to discuss current trends in practice and make recommendations to better manage the pediatric asthma population

Medicaid Case Manager

Developed, implemented and monitored cost effective clinical and utilization management initiatives while improving the quality of care of members. Promoted to Manager, Disease Case Management, promoted in 1999.

Hahnemann University Hospital, Philadelphia, PA                                       June 1989-May 1998

Staff Nurse, Cardiothoracic Surgical Unit                                                                                          

Staff Nurse/Lead Associate (Assistant Head Nurse)             

Medical Cardiology Telemetry Unit                                                                                                                          

Staff Nurse, Medical Surgical Unit   

University of Pennsylvania, Wharton Executive Education: 

Leadership Program, 2007 – 2008

Finance and Accounting for the Non-Financial Manager, 2006

Hahnemann University, Philadelphia, PA

Bachelor of Science – Nursing, 1998

Associates Degree – Nursing - Magna Cum Laude, 1989

Certification Case Management, 2012 – Present

Registered Nurse, 1989 – Present (Licensed in DE, PA)