Jaymie Billbrough is registered nurse and Senior Consultant with BluePeak Advisors. She has over 25 years’ health care experience in government programs holding management positions for national and regional managed care organizations and worked for the Centers for Medicare and Medicaid Services, (CMS), for over 7 years. She has extensive business and regulatory knowledge of Medicaid, Medicare Advantage and Prescription Drug Plan operations including, policy, audit, compliance, utilization management, quality assurance and operational process improvement. At BluePeak, Jaymie consults with health plans and their contractors on compliance, medical management, operations and STAR improvement activities. Jaymie assists plans and their delegates with government audit readiness by performing mock audits, education and training. Jaymie also performs CMS validation audits for Parts C Organization Determinations, Appeals, and Grievances, (ODAG) and D Coverage Determinations, Appeals and Grievances, (CDAG) and assists plans with remediation efforts and process improvements.
Prior to joining BluePeak, Jaymie was Director of Operational Excellence at a large regional plan responsible for the Medicare Advantage and Prescription Drug and Medicare Supplement operations process improvements and quality programs. She was responsible for analyzing new and existing operational guidance as well as implementing and ensuring controls were in place for updated and/or new regulatory or business requirements. This included CMS and State audit preparation and corrective actions responsibilities as well as supporting National Committee for Quality Assurance, (NCQA) initiatives. Prior to holding this position Jaymie was the Head of Medicare Star Strategy for a large national health plan. She was responsible for organization-wide leadership and development of an integrated approach to improve Medicare Star ratings. At the same national health plan, Jaymie served as the Medicare Compliance Officer for over six years. In this role, she oversaw all aspects of the Medicare, Individual and Medicare Supplement Compliance Programs. This included the annual development and ongoing oversight of the compliance plan and monitoring of medical management, operations, pharmacy and other delegated vendors. In addition, she was responsible to coordinate and respond to legal and regulatory obligations, develop risk assessments, improvement and corrective actions plans, design and deliver training and education programs. Jaymie managed all external government audits, surveys and inquiries from CMS, Office of Inspector General (OIS), MEDIC, State Insurance Health Plans (SHIPS), State Pharmacy Assistance Plans (SPAPS), States and other regulatory bodies.
Prior to her health plan work, Jaymie was a Health Insurance Managed Care Specialist with CMS, overseeing Medicare Advantage and Prescription Drug Card Contracts. She was responsible for program requirements, interpretation of new and existing regulations, and was the daily liaison to HMO, PPO, PFFS Managed Care Organizations and DOD contractors. She performed health plan audits, developed corrective action reports, approved new applications and performed ongoing contract assessment and monitoring.
Throughout her career Jaymie has utilized her clinical background supporting various quality, utilization and care management initiatives and has extensive experience in direct management of plan operations, compliance and clinical staff. Jaymie has also worked for PriceWaterHouseCoopers as a senior consultant of Medicare Managed Care & Provider Service Organizations and has performed clinical nursing services at several large hospital systems.