58% → 96%
Care Plan Quality — 3 Months
Partnered with clinical leaders to translate regulatory requirements into improved workflows, producing a 38-point increase in average care plan audit performance within three months.
Healthcare Operations · Clinical Leadership · Quality Improvement
Raynie Fike, RN, CCM
I lead healthcare transformation at the intersection of clinical operations, care management, quality, and regulatory performance—turning complex requirements into scalable workflows, stronger teams, and measurable outcomes.
15+ years of healthcare leadership across managed care, ambulatory care, home-based care, pediatric acute care, skilled nursing, and population health.
Selected Results
Leadership impact at a glance
11 Days → ~3 Days
Transition-of-Care Timeliness
Strengthened workflows and accountability around post-discharge care coordination and follow-up.
~40 Staff · 4 States
Regional Clinical Leadership
Led four teams across Arizona, Utah, California, and Colorado supporting complex, chronically ill members across a multi-state care model.
18% ↓
Avoidable ED Admissions
Helped implement post-discharge texting and a nurse-led ED diversion pathway with priority specialty access, reducing avoidable ED admissions by 18% over six months.
What I Do
Turning healthcare complexity into clear execution
Clinical Operations
Translate strategy into practical workflows across case management, utilization management, transitions of care, complex care, and population health.
Quality & Performance Improvement
Use data to identify where systems break down, why variation occurs, and which interventions will produce measurable improvement.
Healthcare Transformation
Redesign workflows, implement clinical processes, improve adoption, and connect regulatory requirements to day-to-day operations.
Regulatory & Compliance
Experience across NCQA, HEDIS, CMS, Medi-Cal, CalAIM/ECM, MCG, clinical documentation, and audit readiness.
Selected Work
Five leadership stories. One operating philosophy.
01 · CURRENT QUALITY TRANSFORMATION
58% → 96% in the First Month
Challenge: ECM care plan audits revealed meaningful documentation and quality gaps, with baseline performance averaging approximately 58%.
Leadership strategy: Partnered with clinical leaders to translate DHCS and managed care plan requirements into practical workflows. Educated leaders on regulatory expectations, identified process improvements with the greatest quality impact, and supported implementation across clinical teams.
Measured impact: Average care plan audit performance increased from 58% to 96% within three months while the redesigned process also reduced documentation burden.
Sustaining the change: Used Quality team audit results to identify remaining variation, then developed and delivered frontline education designed to sustain performance in the high 90s and strengthen ongoing DHCS and managed care plan audit readiness.
02 · PEDIATRIC ACUTE CARE
18% Reduction in Avoidable ED Admissions
Post-discharge innovation: Helped implement text-based follow-up that enabled frontline care-management staff to proactively connect with patients and families after discharge and intervene when community supports, appointments, equipment, or other elements of the discharge plan were delayed.
ED diversion: Paired this with a nurse-led pathway that empowered ED nurse case managers to use clinical judgment and directly access priority next-day specialty appointments when expedited outpatient care could safely prevent an avoidable acute-care admission.
Measured impact: Avoidable ED admissions decreased by 18% over six months.
03 · MULTI-STATE COMPLEX CARE
~40 Staff Across 4 States
Regional scope: Led four teams across Arizona, Utah, California, and Colorado supporting a highly complex population representing approximately the top 5% of chronically ill members in the Optum program.
Urgent care model: Helped operationalize an in-home urgent visit workflow in which paramedics or LPNs evaluated members and connected virtually with NP or physician staff, creating an alternative pathway when appropriate to reduce avoidable acute utilization.
Continuity: RN case managers closely managed urgent episodes, including proactive weekend “tuck-in” calls, while acute admissions triggered structured transitions-of-care follow-up, evidence-based clinical oversight, and tightly coordinated EMR workflows.
04 · VALUE-BASED AMBULATORY CARE
Readmissions Below 13%
Challenge: Improve post-acute follow-up and reduce avoidable readmissions across a multi-site ambulatory care environment.
Approach: Redesigned transitions-of-care workflows, standardized outreach expectations, strengthened high-risk chronic disease oversight, and built more consistent accountability across interdisciplinary teams.
Measured impact: Hospital readmission performance improved to below 13% while supporting broader NCQA PCMH and patient-centered care goals.
05 · REGULATORY & CLINICAL QUALITY
8 Deficiency-Free Surveys + 5-Star Annual Survey
Leadership scope: Oversaw clinical operations, staffing, infection prevention, regulatory compliance, quality, and financial performance in skilled nursing.
Measured impact: Led infection-prevention strategy through eight consecutive deficiency-free AZDHS infection-control surveys and implemented nursing-practice and quality initiatives that contributed to a 5-Star Annual Inspection Survey.
“I don’t just identify compliance gaps. I translate requirements into clinical workflows, align leaders around the change, measure the results, and equip frontline teams to sustain it.”
Leadership Philosophy
Develop people. Improve systems. Measure what matters.
I believe strong healthcare leaders create environments where employees understand the mission, know what success looks like, and have the tools and support necessary to achieve it.
Clarity
Development
Accountability
Psychological Safety
Continuous Improvement
Patient-Centered Execution
Executive Value
What I bring to a leadership team
Build scalable systemsTurn complex clinical requirements into workflows teams can actually execute.
Develop leaders and frontline teamsCreate clarity, education, accountability, and feedback loops that sustain change.
Connect quality to operationsUse data, audits, and frontline insight to identify root causes—not just symptoms.
Lead across the continuumExperience across Medicaid, Medicare Advantage, ambulatory, home-based, acute pediatric, and skilled nursing environments.
About
A clinical leader with an operational lens
I am a Registered Nurse and Certified Case Manager with experience spanning hospital care, utilization management, case management, healthcare operations, quality, and value-based care.
Working across hospitals, health plans, provider organizations, and complex-care environments has shaped how I lead: healthcare problems rarely exist in isolation. The strongest solutions align people, process, technology, quality, and clinical outcomes.
Let's Connect
Interested in healthcare leadership opportunities where improvement has to be measurable.
Résumé download is included with this portfolio package.