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michelle boltonMichelle Bolton, MBA, BSN, RN, RN-BC, CPHQ

Consultant | BluePeak Advisors

Michelle Bolton is a Health Plan Services Consultant at BluePeak Advisors, a division of Gallagher Benefit Services, Inc.  Michelle is a Registered Nurse and has served as a senior healthcare administration executive with more than 15 years of experience in managed care at the corporate and local plan levels. Michelle has extensive knowledge of Medicare Advantage, Medicaid, and marketplace contracts and health plan operations; with specific expertise in external quality review audit readiness, grievance and appeal operations, HCBS 1915(c) waivers, HEDIS operations and outcome interventions, NCQA accreditation processes, quality of care investigations, and risk adjustments.  Michelle has served as the grievance and appeals subject matter expert for a large managed care corporation before, during, and post Request for Proposal (RFP) and has lead implementations in new markets standing up the appeals and grievances operations and department.  Michelle has served as the operational department head for appeals for the ODAG and SARAG areas of CMS Audits. Michelle has also led health plan quality teams through state audits with their external quality review organizations and implementation readiness audits with various state auditors within the Medicaid product.

Prior to becoming a Consultant, Michelle worked as a Senior Director for one of the nation’s largest national managed care organizations and created end to end programs and process improvements around appeals, grievances, quality of care, and critical incident investigations. Michelle has a proven record of reducing operating costs and improving efficiency in multiple areas of health plan operations. During her time as a Regional Director of Quality she increased the engagement of plans within her region and developed and led a national grievances and appeals support team improving health plan processes, turnaround time outcomes, and NCQA STARs performance. Michelle led and managed virtual and in person large teams working closely with business analysts, community organizations, physicians, regulatory agencies, executive leadership, and front-line staff members.

Michelle has been instrumental in various system migrations and upgrades for appeal operations. She has experience as the product owner, as well as business owner and ensuring compliance and audit readiness through these migrations. Michelle served as the subject matter expert for the appeal operations developing a cloud-based appeal module for the Medicaid, Medicare, and marketplace products. Michelle also specializes in Root Cause Analysis, Gap Assessments, and Remediation Plans for appeal operations.

Michelle holds an MBA in Healthcare Administration from Ohio University.

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Experienced Medicare staff: Ready when you are!

BluePeak knows how difficult it can be for Medicare Advantage plans and TPAs to find knowledgeable resources with experience in Medicare, especially when demands increase sharply given the Medicare annual cycle. BluePeak maintains a wide variety of experienced Medicare personnel to help you with seasonal projects, operational backlogs, compliance monitoring, remediation activities, and more.

Examples of projects that BluePeak has assisted plans in 2022 include:

  • Clinical chart review by licensed clinicians
  • Call center oversight, including listening to calls for accurate classification and calibration
  • Operational support to resolve grievance backlogs and provider directory compliance
  • Pharmacy support to resolve coverage determination backlogs
  • Program area specific operational and administrative responses to a corrective action (initiated internally or externally)
  • Compliance resources to support compliance program initiatives

Whether you need one resource or many, BluePeak can quickly staff any project, train resources, track results, and deliver success.

Contact us today!