SUMMARY OF QUALIFICATIONS

• Trained and experienced professional in the Health Care Management, both in physical and mental health scenarios.
• Strong experience in detailing with physicians and health care facilities administrators.
• Over ten years of knowledge and experience in Health Care Reform and Medicare laws, rules and regulations applicable for Medicare Advantage.
• Project Management of Risk Adjustment optimize premium for Medicare Advantage Health Plan.
• Experienced in negotiation and establishment of fees in Health Care Reform.
• In charge of committees periodic meetings.
• Responsible of Management and coordination with departments related to Health Care Reform and Medicare Advantage process.
• Monitoring pharmacy and medical services claims adjudication and follow up to ensure resolution- Claims Management Tools.
• Pharmacy and Medical Services Claims Monthly and Annual Financial Reconciliation
• Liaisons with vendor' s, contractors and providers related to the execution of Medicare Risk Adjustment processes.
• Perform reconciliation Amount charged to Medicare and Health Care Reform Ipa' s, including pharmacy claims.
• Responsible of calculate gap process, Stop Loss, reporting and monitoring.
• Responsible of monitoring utilization to specific members and PCP' s within the plan coverage' s.
• Responsible of maintain knowledge of claims adjudication and utilization analysis for support operational and business processes.
• Responsible for the monitoring of all utilization indicators related to the claims adjudication, and present findings and recommendations.
• Coordinate and participate in the development of trainings for meetings between internal and external members, in hospitals and health insurance agencies.

EDUCATION

Master of Health Services
Bachelor in Sciences

PROFESSIONAL EXPERIENCE

Confidential, Consultant
September 2005- Present

Project Management of the Risk Adjustment Project to optimize premium.

• It includes the coordination of all activities, and plans with all Health Plan related areas to implement the project and meet health plan corporate goals.
• Assist Health Plan in the monitoring of all activities and tasks related to the project to make sure all activities are on track and according to the timeline established.
• Assist Health Plan in the preparation of detail work plan, timeline, production and metrics reports and other management reports to monitor the project.
• Assist Health Plan in the monitoring of external vendor performance related to medical records retrievals, imaging process and coding for date of service.
• Identify gaps in the Risk Adjustment processes and methodologies and provide recommendations to Health Plan management team.
• Assist Health Plan management team in the development and implementation of risk adjustment strategies to meet the Premium Optimization Goal.
• Establish the relationships with providers (physicians, specialties and facilities) and coordinate appointments with them to obtain the medical records needed for risk adjustment processing.

Mental Health Management.

• Process Analysis
• Billing and Collection
• In charge of committees periodic meetings.
• Proposals
• Strategic Planning
• Negotiates with the third party payers
• Joint Ventures in Health Care Reform with third party payers

Coordinate with clients professional services contracts.

• Providers contracts for the network
• Liaison between the third party payers and the providers.
• Billing and collection of medical plans
• Conducting Need Assessments
• Conducting Reengineering studies
• Conducting Health Clinics
• Conducting studies at hospital institutions
• Visit medical plans to:
• Audit billing process
• Deliver invoices
• Obtain clients provider number

Utilization Analysis in Medicare Advantage and Health Care Reform

• Claims analysis
• Statistics
• Protocol
• Cost Contention
• Presentations for doctors/providers

• Responsible for the organization, administration and the adequate operation of different areas of the department.
• Review and develop a plan of correction for the deficiencies found by the inspectors of the accrediting agencies and assure the same are corrected.
• Participate in the evaluation, selection and integration of technology and management information systems that provide support to the needs of patient care.
• Cooperate in the development and implantation of policies and procedures that serve as guide and support to the services offered by the department.
• Participate in the planning and implementation of optimum quality services in accordance with the Medical Director of the department.
• Analyze production data of the department to visualize tendencies, process deviation and concerns of patients to determine cause and correct these.
• Participate in the development, implementation and evaluation of programs that promote recruitment, retention and continued education to the personnel.
• Establish work plans with the supervisors at his charge to comply with programmed goals.
• Responsible for the security measures and hygiene for infection control, together with the Infection Committee.
• Develop, together with the Environmental Committee of Care, Program of Security, Fire and Disaster; assures an adequate management of patients in the implementation and during the duration of emergencies and evaluates the obtained results.

• Participate as active member of the Administrative Medical Board and submission of protocols for their approval; as well as serving as liaison for any event and/or situation.
• Prepare and document organization' s strategic plans.
• Serve as coordinator between Medical staff, Administrative Medical Board, Executive Director and Board of Directors.
• Coordinate daily operations along with the Executive Director.
• Supervise daily operations.
• In coordination with the Finances Director, maintain and guarantee economic stability of the institution.
• Prepare annual budget.
• Develop and maintain an effective public relations' program for the institution.
• Serve as an active member of the Safety and Security, Quality control, and the Control of Infectious Diseases Program' s committees.
• Participate in Board of Directors' meetings.
• Establish and Implement rules and regulations and policies for the personnel, with the previous approval of the Board of Directors.

• Coordinate administrative and managerial activities at the hospital, with special attention to the Emergency Room Unit.
• Coordinate managed care with hospital clinical staff on a 24- hour shift and every other weekend.
• Evaluate function of the different departments.
• Keep and assure physical facilities' quality and safety.
• Promote and assure effective communications with the medical faculty.

RESEARCH SUBMITTED, PUBLICATIONS AND PRESENTATIONS

• Reingeniería del Proceso de Pruebas Diagnósticas de Radiología en el Hospital Y (August 2002).
• Reingeniería del Proceso de Admisiones Pediátricas en el Hospital de la Universidad de Puerto Rico en Carolina (May 2001).
• Estudio de Necesidades en el Municipio de Juncos (October 2001).
• Percepción de la Facultad Médica del Hospital X con respecto al Proceso de Admisión (August 2001).
• Planificación Estratégica en Atlantic Medical Center en Manatí, Puerto Rico ( March 2001).
• Medicare: Contratación de facultativos para Sala de Emergencia. Presented at the Menonita General Hospital for the Medical staff. (August 2002).
• Asistencia y Presentación de un tema. Presented at the Menonita General Hospital for the clinical staff as part of the course- Mejoramiento de Calidad. (March 2002).
• Medicare Plus Choice: Laws and Regulations. Presented at the Menonita General Hospital Board of Director' s Meeting. (January 2002).
• Special Project: Hyperbaric Medicine. General Concepts, DRG and reimbursement, medical insurance covered, Billing Requirements and Payment Requirements. Presented at the Hospital Interamericano de Medicina Avanzada de Caguas, Operational Committee Meeting. (December, 2003).
• Medicare:Medicare Prescription Drug, Improvement and Modernization Act of 2003 (Pub.L.108-173). Presented at the School of Pharmacy, as a continued education (December 2004).
• Medicare Concepts Presented at the School of Public Health, as a conference in Administrative Aspects (2004,2005,2006,2007,2008,2009,2010).
• Puerto Rico Health Care Reform Concepts Presented at the School of Public Health, as a conference in Administrative Aspects (2004,2005,2006,2007,2008,2009,2010).
• Medicare:Medicare Prescription Drug, Improvement and Modernization Act of 2003 (Pub.L.108-173). Presented at the School of Pharmacy, as a continued education (December 2004).
• Reforma de Salud y las Personas de Edad Avanzada. Presented at the "Primer Simposio de Gerontología en Puerto Rico, Del Discurso a la Acción" (October, 2006).
• Medicare and Puerto Rico Health Care Reform Concepts Presented at Ponce' s School of Medicine, as a conference in the Graduate School of Psychology (April 2008 and June2008).

COMPUTER KNOWLEDGE/COMPETENCE

• Excellent Analytical Skills.
• Experience in auditing Medicare and Health Care Reform Claims.
• Knowledge in Word for Windows, Excel, SPSS, Epi-Info, Sabiamed & HMO Medical Auditor.
• Experience in manipulating high volume of data.
• Excellent Power Point presentation Skills

OTHER INFORMATION

Languages

• Spanish and English