• Acted as a Regional Lead to partner with Health Plans, Vendors, and Providers supporting Risk Adjustment initiatives; with a strong focus on bidirectional data exchange initiatives, from initial engagement, implementation, and continual workflow optimization and education.• Identified resources, resolved issues, and mitigated risks. Identified procedures and problems to improve existing processes. Coordinated cross-functional meetings with various functional areas to meet overall stakeholder expectations and business objectives. Managed projects through the full project life cycle and provided leadership and effectively communicated project status to all stakeholders.

• Performed chart audits and data abstraction to improve quality and Hedis scores. Analyzed health information to determine trends and areas needing improvement. Communicated findings with providers and staff regarding proper documentation and addressing Hedis measures. Abstracted data and sent to payors such as Medicare Advantage plans and commercial insurance. Created standard work processes for department outreach.• Piloted a records-recovery project at a clinic in Colorado Springs. Created a new process flow for processing incoming patient records electronically instead of manually which decreased record downloading time by 50%. Helped the clinic get to baseline and shared sustainable best practices with the office manager.

Educated physicians on proper medical record documentation. Focused on addressing and documenting chronic diseases for risk adjustment. Demonstrated tools in Epic EMR that saved provider time and assist with managing chronic conditions.

• Managed 40 provider contracts monthly to improve patient quality outcomes with an interdisciplinary team. Educated providers and staff on proper medical coding/risk adjustment, documentation, CAHPS/HOS, and HEDIS measures based on CMS regulations. Conducted compliance reviews of charts, root-cause analysis, and data analysis of provider Hedis performance and implemented action plans and process improvements.• Attended Joint Operational Committee meetings and gave lectures to groups on their quality scores and created innovative strategies for improvement within their organization. Managed HMO optimizations.

Home Health Utilization Management:• Made Medicare determinations for skilled nursing, physical / occupational therapy, and home health. Processed denials and sent cases to medical director for review. Telephonic Transitional Care Manager:• Managed patient caseload: discharge planning, telephonic assessments, and arranging the receipt of products and services post- hospital discharge. Monitored and educated Medicare members on their disease processes and on self-management to avoid hospital readmissions. Caseload readmission rate was 12%: under the average hospital readmission rate of 15%.

• Reviewed and processed Medicaid medical appeals in accordance with InterQual and Aetna criteria. Created a medical review summary protocol to insure timeliness of appeals. Increased time compliance from 76% to 96%. Decreased physician review turnaround time by 50%.• Experienced with concurrent and retro reviews of the following cases: Hospitals, LTAC and Rehab facilities, DME, pharmaceuticals, Skilled Nursing, Physical Therapy, Occupational Therapy, and Speech Therapy

• Processed Medicare precertifications and created authorizations for DME, specialist visits, and medical/surgical procedures according to Milliman guidelines. Managed denials and appeals.• Directed physicians and members to appropriate and cost-effective routes of health management which reduced fraud, waste, and abuse of resources.

• Performed telephonic assessments of Medicare/Medicaid members with complex disease diagnosis. Managed member care arranged the receipt of needed resources and services post-hospital discharge. Provided healthcare counseling and coordination of care which reduced hospital readmissions. • Created authorizations for DME, skilled services, and referrals. Investigated fraud, waste, and abuse of DME and health services by analyzing and evaluating medical claims.