SUMMARY

• 15 years of healthcare experience for enterprise level projects and initiatives with healthcare payer and provider companies in the Southern California area.
• Project Manager/Coordinator for an enterprise initiative of over $35 million dollars.
• 1/7 Project Managers, a Project Coordinator, and 400 resources both on - site and remote supporting the project at OPTUM.
• Work with project coordinator in managing two health plan audits that included 201 member counts for auditing of chronic HCC codes for prep and submitting to assigned vendors for chart retrieval and coding.
• The Work flow processes were managed by MS Project and submitted to the Optum executive team by Power point presentation for reporting to the Health Plan for the results
• Manage, analyze, strategize, create, improve and implement new operational processes across various function areas of Medicare Risk Adjustment including the submission of claims, provider education, data analysis and audits, data management that includes vendor management oversight and processing of Risk Adjustment Attestations for CMS audit submissions including Risk Adjustment Data Mining efforts within HCC reconciliation project efforts.
• Expertise in Medicare, Commercial, and Medicare Risk Adjustment with operational leadership and project management experience that includes hire, manage, directs, motivates departmental staff, management professional.

TECHNICAL SKILLS

MS Office Suite: Project, Access, Excel, SharePoint, PowerPoint, Word, Outlook, EZ-Cap, IDX, Encoder Pro, Caremark, Ascender and Health Risk Partners, EPIC, 3M, Cerner, CDAT, NextGen.

PROFESSIONAL EXPERIENCE

Project Manager

Confidential, Irvine, CA

Responsibilities:

• Assemble, develop and refines/improves the key operational components necessary for multiple concurrent initiatives with shared services, USC Keck operations, Information Technology, health plan and external partners.
• Build a common model for operating all programs with internal and external experts to identify and analyze for gaps improvement opportunities.
• Created and executed specific deliverables and activities within the Cerner and NextGen database.

Project Manager

Confidential, Santa Ana, CA

Responsibilities:

• Project Manager/Coordinator for an enterprise initiative of over $35 million dollars.
• 1/7 Project Managers, a Project Coordinator, and 400 resources both on-site and remote supporting the project.
• Work with project coordinator in managing two health plan audits that included 201 member counts for auditing of chronic HCC codes for prep and submitting to assigned vendors for chart retrieval and coding.
• The Work flow processes were managed by MS Project and submitted to the Optum executive team by Power point presentation for reporting to the Health Plan for the results.
• CMS RADV contract-level audits for HCCs, submit results through CDAT for CMS Medicare Advantage Review the quality of risk adjustment data submitted for payment by MA organizations.
• Determine beneficiary risk scores/risk - adjusted reimbursement on enrollee diagnosis, as specified by ICD-9 CM to prospectively adjust capitation payment for a given enrollee based on health status.
• Develop using Medicare fee-for-service claims data to identify HCC risk score for each enrollee.

Program Administrator

Confidential, Santa Ana, CA

Responsibilities:

• Monitor MMR/MOR reports for HCC data.
• Manage health plan data validation projects (RADV, STARS, P4P, HEDIS).
• Complete corrective action plans upon request by Health plan.
• Analyze and track lost revenue from chart review/suspects/ Part D/homebound/AWV.
• Work with network providers for general risk adjustment education.

HCC/HEDIS Analyst

Confidential, Long Beach, CA

Responsibilities:

• Reviewed and identified high risk diagnosis codes as probable suspects from HEDIS measures.
• Extracted HEDIS effectiveness of care measures for Commercial/Medicaid/Medicare members for NCQA’s HEDIS performance measures.

Project Analyst

Confidential, Anaheim, CA

Responsibilities:

• Chart review of HCC coding sweep project, managed remote coding team and HCC reporting of analytical data.

Risk Adjustment Manager

Confidential, San Dimas, CA

Responsibilities:

• Extract, analyze HCC risk adjustment and ICD-9 data for CMS sweeps.
• Develop, implement and review coding compliance from physician clinical documentation, risk adjustment reports and applications from outside vendors.
• Manage and over see HCC department staff (clinical coding auditors, independent contractors, external vendors).
• Responsible in assuring that all pertinent clinical information impacting the risk scoring of members is captured and transmitted to CMS, Conducted educational coding classes for network providers and clinician staff.
• Manage CMS/RADV audits for readiness and insured all process and criteria are in compliance for CMS submission.
• Focused on members with multiple chronic illnesses and in corporate the best practice in intensive case management, disease management, behavioral health and care coordination for high risk and high cost patients through individualized care management.
• Proactively developed and updated policy and procedures for risk adjustment in compliance to CMS.

Reimbursement Specialist Manager

Confidential, Orange, CA

Responsibilities:

• Managed inpatient/outpatient charges, posting, and billing and collection operations, ensured accurate and timely billing was in compliance by staff members.
• Supervised procurement insurance and financial obligation information on patient’s ability to pay for treatment and coordinate with credit/collection staff members on evaluation of patient’s benefits and review of applicants to determine free care allocations and programs.
• Monitored activity reports with collection agencies, admitting, third party approvals and indigent programs.