innovative Transitional Care Programs (SHARP, Transition Guides, Community Health Workers), and developing documentation and analytics to capture KPI's, improving quality metrics and improving outcomes. -Knowledgeable of Value Based Care models, Accountable Care Organizations (ACO), JCAHO, NCQA, MIPS, QRS, HEDIS, CAHPS, Patient Driven Groupings Model (PDGM) measures and requirements. -Serves on senior leadership committees for five hospitals and identifies forward-thinking programs for departments and community agencies an active member of the skilled nursing facility collaborative to improve communications and safe transfers to another level of care, reduce readmissions and total cost of care for diverse populations. -Leads practice-based meetings with providers and teams to identify gaps, review high utilizer and rising needs patients utilizing various risk stratifying tools, case studies and analytics providing real-time solutions to improve quality metrics, reduce barriers and promote team based-care. - Responsible for the hiring and professional development of high-quality staff driving a care coordination model of excellence innovation in practice, quality assurance, best practices, community partnerships, accountability, quality improvement, to achieve organizational goals in a supportive and dynamic environment. -Laser focused on meeting strategic priorities, improving analytic capabilities, and both patient and staff education to improve performance metrics, compliance, and drive decision-making.