Perform gap analysis and conduct root cause assessments of departmental processes for client delivery and business risk mitigation. • Fluent in Mural, Miro, Vizio, Excel, Microsoft, SharePoint, Tableau, and many additional internal supporting systems (ChartPoint, PCH, CPA, etc.). • Completed Diagnosis Related Grouper (DRG) Pre-Pay & Post-Pay Optum Workflow Miro’s documentation for scheduler’s and CAT’s appeal process.• Team Lead for integration into Optum’s Denial Letter Queue… Show more Perform gap analysis and conduct root cause assessments of departmental processes for client delivery and business risk mitigation. • Fluent in Mural, Miro, Vizio, Excel, Microsoft, SharePoint, Tableau, and many additional internal supporting systems (ChartPoint, PCH, CPA, etc.). • Completed Diagnosis Related Grouper (DRG) Pre-Pay & Post-Pay Optum Workflow Miro’s documentation for scheduler’s and CAT’s appeal process.• Team Lead for integration into Optum’s Denial Letter Queue. Developed over 50 documents related to Miro’s, training materials, and process flows, production and reporting metrics.• Special Projects for Optum Management. Basic Microsoft production, employee and internal documentation handling, to townhall content and presentations. • Main Liaison between Optum and Change Healthcare Staff during Onboarding, (in 17 Business Days), impacting 41% (28K+ Denial Backlog Processed) of Denial Letter backlog, completing that 70K backlog by May.• Re-built and Integrated Hourly Production Tracking, Quality Assurance (QA) metrics, and training for audits to take place. Show less

Built a foundational team to mitigate risk and maximize operational excellence through a variety of roles to include Quality Assurance, Compliance, Appeal, and Provider Database Analysts while promoting Change Healthcare’s Culture, Diversity, Equity & Inclusion principles (Leadership DNA) and fostering teamwork.• Created and compiled a team of internal QA analysts.• Built a QA Program for internal audits impacting over 80+ team members. Rectifying PHI, revenue, and human error issues… Show more Built a foundational team to mitigate risk and maximize operational excellence through a variety of roles to include Quality Assurance, Compliance, Appeal, and Provider Database Analysts while promoting Change Healthcare’s Culture, Diversity, Equity & Inclusion principles (Leadership DNA) and fostering teamwork.• Created and compiled a team of internal QA analysts.• Built a QA Program for internal audits impacting over 80+ team members. Rectifying PHI, revenue, and human error issues. Impacting over $1.75+ Mil in savings.• Collaborated across silos with internal Risk groups, Operations, Refund Recovery, Financial Management.• Documented and tracked internal QA trends and patterns across the Administrative Services Team (AST) in addition to Financial Risk Management and Refund Recovery Departments.• Facilitated monthly Manager Round-table meetings with key stakeholders to identify revenue/PHI/internal process corrections.• Expanded compliance rules/provider matching/appeal handling across all Payment Integrity teams. • Defined process for COVID impacted inventory for DRG/CVA/MNA/ CO service lines. Applied state/client guidelines to reduce risk factors on specific claim(s)/provider(s), etc. • Finalized the departmental Standard Operating Procedures for each team and processed more than 250 manuals across Payment Integrity. Show less

Responsible for development and implementation of quality and inventory systems; developing and managing multi-disciplinary teams to ensure process workflows are executed, compliant with internal procedures and industry regulations, and processed in a timely manner. Currently managing the following teams:• The Quality Assurance team to review and audit various processes within the organization. Also responsible for providing training the staff involved in the audit and remediation… Show more Responsible for development and implementation of quality and inventory systems; developing and managing multi-disciplinary teams to ensure process workflows are executed, compliant with internal procedures and industry regulations, and processed in a timely manner. Currently managing the following teams:• The Quality Assurance team to review and audit various processes within the organization. Also responsible for providing training the staff involved in the audit and remediation process. Implemented and created a new Quality Assurance Program for a staff of 45, encompassing 63 Quality Audit Templates, while housing all templates and tracking documents in new SharePoint site for internal Auditors to utilize with ease. • Lead in the development and implementation of quality and inventory systems. • Develop and implement internal metrics to serve as an effectiveness check for the monitoring of enhanced workflow processes.• The Inventory Management team to ensure that team meets daily, weekly, monthly pushes on a specific subset of inventory at risk, with potential, or revenue driven which requires resolution.• The Appeal Team to identify and process all appeals that are submitted through the electronic system. Appeals workflow include appeal level assignment, prioritization and expedition of appeals based on case status and service line. Show less

Responsible for managing multiple client payment verification inventories. Clients included Aetna, Affinity, Anthem/Empire, BCBS-AZ, BCBS-VT, BCBS-MN, BCBS-ID, Caremore, CCStpa, California Prisons, HealthNow, WellMed, Molina, Cigna Healthcare, Cigna West, Cigna AZ, HCSC, BCI.• Managed multi-person team in the day-to-day and long term strategic plan execution related to the processing and maintaining various client payment inventories. • Assessed and streamlined payment verification… Show more Responsible for managing multiple client payment verification inventories. Clients included Aetna, Affinity, Anthem/Empire, BCBS-AZ, BCBS-VT, BCBS-MN, BCBS-ID, Caremore, CCStpa, California Prisons, HealthNow, WellMed, Molina, Cigna Healthcare, Cigna West, Cigna AZ, HCSC, BCI.• Managed multi-person team in the day-to-day and long term strategic plan execution related to the processing and maintaining various client payment inventories. • Assessed and streamlined payment verification workflows to ensure payments were promptly and accurately processed.• Reconciled and closed-out of aged inventory and end-of-month processes were completed successfully. Show less

Responsible for the enhancement and maintenance of the inventory management system and workflows. Developed and submitted Quarterly Closure report to upper management.• Conducted random internal audits conducted of the Inventory Management of DRG inventory. Identified and obsolete workflow steps that resulted in the reduction by excessive inventory by10%.• Created and updated standard operating procedures, manuals, and forms (upwards of 250 documents) across multiple departments… Show more Responsible for the enhancement and maintenance of the inventory management system and workflows. Developed and submitted Quarterly Closure report to upper management.• Conducted random internal audits conducted of the Inventory Management of DRG inventory. Identified and obsolete workflow steps that resulted in the reduction by excessive inventory by10%.• Created and updated standard operating procedures, manuals, and forms (upwards of 250 documents) across multiple departments. • Developed ongoing process improvement plan for the monitoring and management of operational email boxes, live call sessions, and educational tools for employees.• Developed and implemented internal metrics to serve as an effectiveness check for the monitoring of enhanced workflow processes. Show less

Responsible for enhancing and assuring compliance to multiple client’s guidelines and screening processes and reducing HCA open inventory by 35%. While identifying over 3 million in savings while making selections.• Lead the collaboration of these team members in the enhancement of data review from manual to automated reviews.• Audited and identified data driven trends as defined in DX Codes, Revenue Codes, and provider behavior.• Created and implemented manual/training… Show more Responsible for enhancing and assuring compliance to multiple client’s guidelines and screening processes and reducing HCA open inventory by 35%. While identifying over 3 million in savings while making selections.• Lead the collaboration of these team members in the enhancement of data review from manual to automated reviews.• Audited and identified data driven trends as defined in DX Codes, Revenue Codes, and provider behavior.• Created and implemented manual/training documentation for HCA Screener position. Show less

Responsible for the audit of domestic and off-shore triaged claims for accuracy and handle the completion of the medical records request process.• Processed a triage caseload of approximately 100 claims daily with an average audit score of 99.85% accuracy.• Reviewed and validated incoming claims to ensure compliance with client guidelines and identified claims requiring for investigation. • Reviewed and analyzed historical data and provided to the analytics department that… Show more Responsible for the audit of domestic and off-shore triaged claims for accuracy and handle the completion of the medical records request process.• Processed a triage caseload of approximately 100 claims daily with an average audit score of 99.85% accuracy.• Reviewed and validated incoming claims to ensure compliance with client guidelines and identified claims requiring for investigation. • Reviewed and analyzed historical data and provided to the analytics department that identified low revenue bearing cases. • Participated in system enhancement testing project, creation of new case plans, and creation/implementation of related training documentation. Show less