A Healthcare Director with 26 years of diverse experience in the healthcare industry including healthcare operation, strategy, programs, finance, and healthcare technology systems. Extensive knowledge of Federal and State regulations governing both Medicare and Medicaid Programs and Systems. A driven leader and problem solver with excellent oral and written communicate skills experienced in managing multiple programs and teams. Participated in multiple statewide programs and system implementations.
Director of Health Information Technology Innovation for the Georgia Medicaid Electronic Health Record Incentive Program and Implementation of Health Information Exchange in the state of Georgia. Responsible for the strategic planning and implementation of several multi-million dollar projects for health information technology infrastructure in Georgia leveraging American Recovery and Reinvestment Act ARRA funding through grant awards from the Office of National Coordinators ONC and Health Information Technology for Economic and Clinical Health HITECH funding from CMS. Manage Policy and Technical Development, Design, and Implementation of the Georgia Statewide Health Information Exchange-Georgia Health Information Network GaHIN to assist Medicaid Providers with meeting Meaningful Use and facilitate Consumer Engagement initiatives. Project Director for the CMS TEFT Testing Experience and Functional Assessment Tools Grant. Monitor federal HIT/HIE/HITECH activities and policies and tracking of performance measures that accurately measure and communicate the project's process. Manage State Agencies connection to the statewide HIE, including Georgia Medicaid MMIS, Department of Public Health, DJJ, DHBDD, and DFCS connections to the statewide HIE.
Healthcare Consultant acting as Business/Technical Requirements lead for Phase 1, 2, and 3 Design, Development and Implementation activities for all functional area, Business Intelligence and Webportal, Extraction Translation and Loading ETL , Security HIPAA, HITECH, Trust Model, and Office of Cyber Security , Data Model, Data Delivery, Infrastructure, J-SURS, R-DUR, and Customer Care Center. Managed the Requirements Design Documentation RDD, Technical Design Documentation TDD , and Change Control Documentation. Provide Medicaid expertise as liaison between Medicaid operational policy and technical requirements. Managing a team of six contractors including status reporting, weekly timesheets, monthly invoicing, and project roles and responsibilities.
Program manager responsible for the Georgia Medicaid's Hospital Services Program with an annual budget of approximately 2 billion dollars in expenditures. Developed and implemented monitoring strategies for the hospital program including providers and members. Developed policies and procedures based on analytical program review of member and provider utilization trends and legislative requirements. Developed and updated reimbursement methodologies, DRG and Outpatient CCR, in conjunction with budget recommendations and legislative mandates. Developed and enforced Hospital Utilization Review standards for Georgia Medicaid provider participation. Managed multiple internal program projects within the Georgia Medicaid's Medical Policy Unit. Performed annual ICD-9 updates for Georgia Medicaid. Georgia Medicaid's 2010 Liaison for CMS Payment Error Rate Measurement PERM Program. Developed provider communication which was subsequently adopted by CMS as best/effective practice and became recommended communication standard for other states. Implement CMS Hospital-Acquired Conditions HAC /Present on Admission Indicators editing and reporting for Georgia Medicaid Hospitals. Member of Georgia's ICD-10 transition team and represented Georgia Medicaid on State ICD-10 committee calls. Assisted with reimbursement on cost reports and revenue center allocation. Developed and implemented State Plan Amendments SPA and submitted to CMS for approval. Monitored claims processing, payment system data, and fiscal agent to ensure compliancy with State policy. Managed external clinical peer review organization and developed prior authorization criteria. Worked with Program Integrity Unit on policy enforcement and Fraud and Abuse identification. Developed and conducted state-wide training for providers enrolled in Georgia's hospital program. Contributing writer for GA MMIS RFP Reference, Claims, Prior Authorization, Member, Provider, Web, Financial, and Reporting and the Medical Management Contractor MMC RFP. Evaluator for Georgia MMIS, MMC, Georgia Cares MCO , Non-Emergency Transportation, State Health Benefit Plan, and Pharmacy Benefits Manager PBM RFP's.
Lead MMIS Policy Business Lead
Lead Requirements Gathering and Definition, Design, Development, Implementation, and System Testing for Georgia Medicaid MMIS Benefit Plan Administration, Reference, Claims, Prior Authorization, and Web portal Subsystems. Aligned Business Processes to Medicaid Information Technology Architecture MITA . Acted as Subject Matter Expert SME and Program Policy Liaison for all 69 Georgia Medicaid program policy areas. Resource for Provider, Member, TPL, Medicare Crossover, Finance, Reporting, Program Integrity, Data Warehouse, Data Conversion, Internal and External System Interfaces ETL Process, and Managed Care. Translated business requirements into technical functional solutions for Medicaid stakeholders and business users. Lead weekly business lead meeting for project documentation, project summary dashboards, best practices, staffing resources/SME identification, project risks, and solutions. Collaborated with system architect to identify software design changes including cross-functionality, hyper-linking, data display, storage, user ability and view ability of windows/panels which resulted in changes to the base product. Identified system data elements for data warehouse and State and Federal reporting requirements. Performed detailed programmatic review of all queries and reporting requirements to determine existing and new reporting requirements to facilitate improved program management. Defined canned reports, on-line reporting, and adhoc reporting data elements and design/format layout requirements. Defined SURS and HEDIS metrics and incorporated into data warehouse for reporting. Responsible for overall review and approval of each SDLC implementation deliverable including the Requirements Analysis Design Document RAD , Business Design Document BDD , Technical Design Document TDD , System Documentation, Operational and Procedure Manual, Use Case design, and Testing. Conducted and participated in pre-readiness and readiness testing and review, approved system capabilities, testing results, and deliverables. Performed User Acceptance Testing UAT and End-to-End testing for various subsystems. Participated in the identified, tracking, and resolution of project risks, issues, and action items.
Patient Financial Services Supervisor
Supervised staff of 10-15 in billing, follow-up, and collections for hospital services. Managed over 200 insurance, managed care, workers compensation, Medicare, and Medicaid contracts by implementing billing procedures in accordance with contract requirements and federal and state policy. Trained staff on medical and billing software and annual software vendor's user's conference participation. Developed and implemented the outpatient billing department and facilitated the return to in-house billing and collections for the hospital. Participated in Performance Improvement Teams for Managed Care, Reimbursement, and Shepherd Workgroup to respond to industry operations. Lead dispute resolution on Managed Care reimbursement, Workers Compensation, Medicare, and Medicaid. Implemented internal and external reporting requirements and report design. Performed annual review and update of Charge Master including Procedure codes CPT, HCPCS and ICD-9 codes. Coordinated and led monthly meeting with CFO on budget trending and provided financial recommendations to help maintain costs. Implemented standardized processes, procedures, and tools to support core project management activities including project management status reporting, monthly steering committee reports, change control processes, and change control board, and deliverable review processes, and monthly reports to CMS.
Coordinated patient in-take, insurance verification, prior authorization, billing, and physician/staff education for Development Pediatrics, Psychiatry, Social Work, Speech Therapy, Physical Therapy, Occupational Therapy, Neuropsychology, Babies Can't Wait, Children's Intervention Services, CCSP, Case Management, and Independent Care Waiver Programs. Performed medical billing software updates for CPT, HCPCS, and ICD-9 coding changes. Performed month-end AR reconciliation for satellite offices, closeout, and reporting. Performed staff in-services for all managed cared contract changes.
Managed office of 11 healthcare professionals and ten support staff. Responsible for billing and collections of 500,000 monthly accounts receivable, and over 300 insurance claims per week. Negotiated managed care contracts, network enrollment, and credentialing for the practice. Implemented all policy changes with billing and insurance procedures including CPT, ICD-9, and patient billing forms. Extensive knowledge of Medicare, Medicaid, Workers Compensation, and Commercial carrier's regulations and provider guidelines.