Medicaid Industry Who’s Who Series: Sheila Wilson

Medicaid Who’s Who: Sheila Wilson, BSN, RN, CCM – Director of Care Management, Medicaid with Priority Health

Sheila is a Registered Nurse with over 31 years’ experience in both clinical and managed care environments. She has extensive experience in case management, and is especially knowledgeable about the challenges facing the Medicaid population. Currently Sheila serves as the Director of Care Management for Medicaid at Priority Health, a Michigan based company serving HMO, PPO, Medicare and Medicaid members across the State of Michigan. Her responsibilities include the development, implementation and administration of programs to achieve medical cost goals for the Medicaid Business Unit. She directly oversees case and disease management, as well as medical utilization operations. Sheila and her team recently received two prestigious Pinnacle Awards from the Michigan Association of Health Plans for work done to incorporate children with special health care needs into managed care, and for spearheading a pilot project with the use of a medical mobile application for children with asthma.

Sheila obtained her Bachelor of Science degree in Nursing from Alverno College, and has held her Certification in Case Management (CCM) since 1994. She has completed the first year of a 2 year Executive MBA Program with Grand Valley State University. She currently lives in Grand Rapids, Michigan with her husband Bill and daughter Ashley.

At the Medicaid Innovations Conference, where Clay Farris of Mostly Medicaid is the Event Chairperson, Sheila Wilson is presenting the following case study:

Taking a Multidisciplinary Approach to Care Management and Delivery: Creating Provider, Health System, and Community Partnerships
Priority Health created the Medically Complex Children’s Program to improve the member experience. A team of Pediatricians, Care Managers, Community Health Workers, Nurses and Specialists within the Academic General Pediatric Residency Clinic (part of the Spectrum Health System), coordinate care for members and aid with basic needs like food, housing, clothing, medication management and transportation. One of our most vulnerable members, a child whose family was new to the United States, arrived to the hospital with acute liver failure and needed a transplant. His parents lacked the resources that the child needed for proper care, so he was enrolled in the Medically Complex Children’s Program. After he was enrolled, a complex care plan was created with input from all team members, including the member and family. The care team assigned to his case helped plan, anticipate his needs between appointments, provide ongoing reinforcement of the care plan and minimize unnecessary Emergency Department visits. The program focuses on one patient, one family, one care plan and one care team to create a better member experience and better health outcomes!

You can learn more about this topic and the rest of the agenda at

  1. Which segment of the Industry are you currently involved?

I am currently working within the Medicaid Program at Priority Health.  Priority Health is one of 11 Managed Medicaid Health Plans here in the state of Michigan. 

   2. What is your current position and with what organization?

I am the Director of Care Management for the Medicaid Program here at Priority Health.

  3. How many years have you been in the Medicaid industry?

I have been working within the Medicaid Care Management Field since 2002. 

  4. What is your focus/passion? (Industry related or not)

I have a passion and commitment to the underserved in the counties in which I live and work.   Understanding the barriers and challenges to obtaining the needed health and social services by segments of our population who are often overlooked and disenfranchised is a core element of my being.  I believe that we each can impact the trajectory of another person’s life through the hard work and examples that we set for each other.

  5. What is the top item on your “bucket list?”

I actually have two items that occupy the top spot.  I would love to have the ability to go to Washington, meet with our Legislators and discuss some of the current issues facing our Country and our State today.  My minor in college was Political Science, so I have a strong interest in our political system.  On a more personal note, I would love to travel the country, visiting small towns and big cities along the way.  I particularly enjoy the coastal areas and would love to spend some time sailing with my family.

  6. What do you enjoy doing most with your personal time?

I love spending time with my 3 grandchildren.  Time stops whenever they are around.  I love curling up with a good book in front of the fireplace during the cold winter months and tending to my garden during the summer months.

  7. Who is your favorite historical figure and why?

I would love to meet both Hillary Clinton and Michelle Obama.  I think they are both brilliant women who believe in the strength and tenacity of all women.

  8. What is your favorite junk food?

I love vanilla frosted unfilled long johns.  My father use to get them for me when I was a little girl and I’ve loved them ever since.

  9. Of what accomplishment are you most proud?

I am almost finished with my Executive MBA Program. I was able to do this while caring for my 89yr old mother, my husband and 16 yr. old daughter as well as working full time as the Clinical Lead for our Medicaid Product.  So many times, I doubted my ability to do it all and yet have somehow managed to meet the needs of my family and myself, both professionally and personally. 

 10. For what one thing do you wish you could get a mulligan?

Very early in my career, I was given the opportunity to attend an OB GYN Nurse Practioner Training Program at virtually no cost to myself.   I turned down that offer.  I often wonder how different my life would have been had I decided to take advantage of that opportunity.  

 11. What are the top 1-3 issues that you think will be important in Medicaid during the next 6 months? 

  1. With the change of leadership in Washington, I am concerned about the future of Medicaid in general and of Medicaid Expansion more specifically.
  2. Pharmacy cost trends are rising at an unsustainable rate.  There is very little that Care Management can do to impact this as it is largely a pricing/contracting issue.
  3. Payment for Health Care is moving away from a Fee-For-Service Reimbursement Model to a Value Based Reimbursement Model.  I worry that our Provider Partners are not moving as quickly to meet the rapid changes that are State is requiring of its Medicaid Health Plans.