Mike Shook
Director Care and Utilization Management @Health Plan of San Joaquin/Mountain Valley Health Plan
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WORK HISTORY
Director Care and Utilization Management @Health Plan of San Joaquin/Mountain Valley Health Plan
US
Instrumental in the strategy development and implementation of CalAIM initiatives related to Long-Term Care Carve-In, Community Supports, and Transitional Care Services.• Oversight and development of strategies to ensure compliance with DHCS 2024 contract readiness and 2024 Managed Care transition.• Ensure all directives set forth through DHCS All Plan Letters (APL) are updated in policy, process, and oversight for compliance with requirements.• Align processes within Utilization Management (UM) are compliant with regulatory and NCQA requirements.• Development, implantation and monitoring of corrective action plans put in place to ensure compliance with regulatory requirements and as a result of the 2022 DHCS Survey.• Oversee all regulatory and departmental reporting, as well as make recommendations to changes in programming of data extraction, to ensure accuracy and consistency of data.• Direct prior authorization, concurrent review and transition of care teams to ensure alignment with regulatory requirements, as well as efficiencies and ensure members needs are met.• Collaborate with both internal and external providers to ensure an understanding of UM processes and mitigate issues that could impact patient care and regulatory requirements.• Interact with senior leadership to provide updates on process improvement and changing regulations impacting the organization.
EDUCATION
Santa Barbara City College
AS, Health Information Management
CCAC South Campus
AS, Nursing
PennWest California
BSN, Registered Nursing/Registered Nurse
PennWest California
BSN, Registered Nursing/Registered Nurse
ABOUT MIKE SHOOK
Seasoned health professional with 30+ year’s experience. Significant experience in Medical Management, Quality and Performance Improvement, Electronic Health Record implementation (EHR), and Program/Project Management. Looking for new and challenging opportunities to build upon my current skill level and knowledge base.Specialties: Process redesignEHR implementation – EPIC AmbulatoryMeeting facilitationInterpreting and implementing regulatory standardsSurvey preparation; TJC, NCQA, URAC, CMSMedicare Star RatingsMedicaid Quality RatingsHealth Exchange Quality Rating System (QRS)HEDIS improvementCAHPS improvementPay-for-performanceUse of Relational Database Management System (RDMS), to extract data/information for reportingData Analysis – quantitative and qualitativeTraining – classroom and just-in-timeUse of performance improvement tools and principles Lean/Six-Sigma Green Belt
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