1. CHERYL L MONNELL, RN MHI/MHA
Resume
1824 Shadowood Dr. Columbia, SC 29212 | | C: 803-451-1679 | cmonnell@gmail.com
Executive Profile
Dynamic Healthcare Executive with a successful track record resulting in URAC and NCQA accreditation
and successful HEDIS/CAHPS project management resulting in increased Health Plan STAR scores.
Leadership experience in private as well as government health plans, delegation oversight and pharmacy
benefit management. Proven ability to manage HEDIS call center, create Case Management programs,
develop benchmarking statistics, and direct Utilization Management/Second Opinion programs.
 Project Management
 Leadership/Communication
 NCQA/URAC/EQRO preparation and review
 STAR scores
 Performance Analysis
 HEDIS/CAHPS/HOS survey
 Onsite audits for mental health facilities
 RFI/RFP response

2. _____________________________________________________________________________________
Core Accomplishments
 Successfully developed Case Management program
 Developed a HEDIS call center resulting in return of the Quality withhold and highest auto
assignment
 Facilitated an update to the customer service software program company wide that allowed tracking
of HEDIS related calls
 Successfully led TPA in NY through 5 URAC accreditation reviews
 Proven track record of managing large numbers of professional and non professional staff
 Developed benchmarking statistics to establish hiring ratios for case managers
 Established a Pharmacy Prior authorization program including management of chemotherapy
program
 Generated over $1.2 million in client savings and $850,000 in case management revenue through
contract negotiation and case review while supervising the pharmacy benefit program
Professional Experience
Director Quality Improvement Sept 2013- present
WellCare
 Created work plan for fourth quarter push to increase HEDIS rates after acquisition
 Provided class to provider representatives going to physician offices in an attempt to close HEDIS
gaps
 Facilitated UMAC and QIC meetings
 Created a dynamic HEDIS work plan used year round to increase rates
 Planned budget for quality initiatives for 2016 to increase HEDIS rates at least 10%
 Achieved NCQA accreditation within 1 1/2years of opening as new plan
 Rolled out plan for Quality Practice Advisors to meet with practices and teach HEDIS documentation
and coding to all contracted physicians

3.  Expanded use of supplemental data sources for increased HEDIS scores
 Successful in return of state withhold for HEDIS/CAHPS scores
 Created “Bill Above” program providing enhance fee for physicians based on Quality scores
 Successfully led plan to move from a 2.5 STAR score to a 3 STAR score plan rating by NCQA
Quality Improvement Manager 2011-Sept 2013
Absolute Total Care South Carolina
 Provided expertise in HEDIS/CAHPS and NCQA assisting staff with education and training
 Established teams to implement interventions to increase HEDIS and CAHPS scores, focusing on
quality scores that effect state withhold and star enrollment measures
 Coordinated documents and work plan for EQRO review, assisting new Accreditation Manager in
training
 Created first Centene outbound HEDIS call center focusing on state withhold measures
 Facilitated update in CRM software to allow documentation of HEDIS calls and facilitate
communication between departments
 Analyzed data provided by HEDIS medical record vendor and determined need for updated chases,
record retrieval, physician office intervention to achieve a successful HEDIS project
 Created metrics and re-organized credentialing department after prolonged absence of a manager
for oversight
 Enabled oversight of credentialing outsourcing vendor to become compliant with NCQA
 Developed presentations for internal and external audiences regarding HEDIS and improvement of
scores
 Developed HEDIS work plan that is based on the “three legged stool”- population health/extensive
data drill down/and member and provider outreach
Quality Improvement Coordinator 2010-2011
Absolute Total Care South Carolina
 Schedule and plan QIC meetings
 Investigate member quality of care complaints
 Medical record audits for risk management, sentinel events and trending
 Successfully increased the outcome of delegated vendor program from less than 50% on
performance standards to 100%, the first in Centene plans
 Organized and coordinated Joint Operating Committee meetings for delegated vendor program and
assessed performance data, recommending CAP’s and PIP’s when needed
 Developed performance improvement plans required by NCQA and the state
 Coordinated postpartum assessment by homecare vendor increasing HEDIS rate by 10 points the
first year
Clinical Reviewer 2008-2010

4. Qualis Health South Carolina
 Determined the medical necessity and quality of healthcare services by conducting preadmission/pre-
procedure, retrospective, and other utilization management reviews
 Worked with the State to revise their outdated procedure reviews, prior authorization requirements,
and workflow for coding review
 Performed onsite reviews at Psychiatric Residential Treatment Facilities across South Carolina
verifying state guidelines for performance and verifying compliance with contract
 Consulted with MD advisors when clinical failed to meet criteria, quality of care screens, and
other guidelines and made recommendations
 Developed reports and letters regarding Utilization management review and quality of care
concerns
Manager of Quality and Credentialing 2007-2008
Carolina Crescent Health Plan South Carolina
 Initiated Quality and Credentialing plans and work flows according to state contract rules
and meeting NCQA requirements for the initial startup health plan
 Created standard operating procedures for the Quality and Credentialing departments
 Prepared and Conducted Credentialing meetings and QIC meetings
 Responsible for all appeals and grievances, tracking, trending, and reporting to the state
 Hired and trained staff for both Credentialing and Quality departments
 Interviewed and selected delegated vendors for the plan, including medical vendors and
credentialing vendor
 Interviewed and selected disease management vendor to initiate program through drug company to
alleviate costs to the plan
Case Manager 2006 -2007
Carolina Care Plan South Carolina
 Stratified case managed members into three levels and set up care plans for each member
 Developed case management program, including policies and procedures
 Assisted with disease managed population, identifying members and referring to appropriate
vendors
 Transplant Case Management Specialist- coordinated all transplants with Medicare authorized
facilities
 Developed Excel spreadsheets to track case management cost savings
 Assisted underwriters in determination of benefit availability for Individual product line
Supervisor, Pharmacy Benefit Program 2004- 2006
POMCO Syracuse, New York

5.  Developed prior authorization plan for all clients (>15) working with six pharmacy benefit managers
 Developed training program to assist in the transfer from a fully manual system to a fully
computerized prior authorization program
 Transferred program from one location to the other end of the state with no loss in revenue
 Generated over $1.2 million in client savings and $850,000 in case management revenue the first
year through contract negotiation and case review
 Negotiated rates for high dollar drugs with various infusion companies, resulting in savings as much
as average wholesale price minus 40%
 Worked with clients developing strategies to save dollars on prescription drug utilization
 Trained all pharmacy and utilization review staff on review of chemotherapy regimens
 Negotiated contracts with Medco and Curascript for specialty injectables
Manager, Utilization Review and Precertification 1993 - 2004
POMCO Syracuse, New York
 Managed pre-certification, concurrent review, and case management process, taking process to a
paperless system
 Developed benchmarking statistics to defend hiring additional staff when new clients were added (i.e.,
ratio became one registered nurse to every 10,000 eligible employees), presented data to senior staff
for hiring ratios
 Developed and employed internal quality assurance auditing procedures utilizing URAC standards for
a staff of 16 registered nurses, 4 medical assistants, and incorporating physician reviewers
 Successfully led plan through initial URAC survey, then 4 additional accreditation surveys, collecting
all company data, responding to all standards, and meeting with onsite reviewer
 Served as project leader developing homecare manual for all utilization review nurses to utilize so
determinations were consistent across the board; manual encompassed RN, PT, OT, and ST
Other Nursing Experience:
 Island Peer Review Organization- Coding, Medicare, Medicaid review
 General Surgery Team Leader
 Scrub Nurse
 Haemonetics Cell Saver Nurse
 Night Charge Nurse, Intensive Care
 Float- Nursery/Behavioral Health
Education
Masters in Health Care Administration/Informatics 2016
University of Phoenix GPA 3.6

6. Columbia, SC
Bachelor of Science: Healthcare Administration 1995
St. Joseph's College Standish, Maine
Nursing Degree 1985
Onondaga Community College Syracuse, New York
Other Special Training:
Health Care Payment, Learning, and Action Network Team
Volunteer, for Division 6, South Carolina Medical Emergency Corps.
Dale Carnegie Courses
InterQual Criteria including CCMS
Microsoft Excel and Word, I, II, and III
Vistar Credentialing System
Calocus Certification
Seven Habits training
CPR/AID certified

7. Columbia, SC
Bachelor of Science: Healthcare Administration 1995
St. Joseph's College Standish, Maine
Nursing Degree 1985
Onondaga Community College Syracuse, New York
Other Special Training:
Health Care Payment, Learning, and Action Network Team
Volunteer, for Division 6, South Carolina Medical Emergency Corps.
Dale Carnegie Courses
InterQual Criteria including CCMS
Microsoft Excel and Word, I, II, and III
Vistar Credentialing System
Calocus Certification
Seven Habits training
CPR/AID certified