Federal Employee Program HEDIS/CAHPS Outcome Initiatives to improve members health outcomes.

Work with our FEP member and provider Population by providing initiatives and process improvement strategies to improve our members health outcomes.

Quality Clinical Review HEDIS Consultant- Reviewing HEDIS measures for both Commercial & Medicare members, reviewing/retrieval of supplemental data and development of reports related to these measures. Proficient in the reviewing of clinical records for HEDIS audits. Subject Expert for the Federal Employee Program (FEP), Clinical Quality Customer Service & Resources (QCR) HEDIS/CAHPS review/ Intervention Specialist. Proficient in Analytical review of reports and development of Interventions related to results.

Train staff on: Care Management and Claims systems, daily job function, On-Boarding, New Hire Orientation. Certified Interqual Trainer (IQCI) and Certified Professional Coder (CPC). Proficient in creating power point presentations, and training materials. Able to solve must training issues effortlessly. Audited Clinical and non clinical staff for performance review and regulatory guidelines for URAC and NCQA.

Reviewed Retrospective claims for 11yrs and determined medical necessity and payment for reimbursement. Case Manager assisted members with disease management. Concurrent Review nurse reviewed all medical records for BCBS members being admitted at Charleston Area Medical Center. Reimbursement Analysis for provider reimbursement. Assisted in reviewing billed codes by providers and establishing a fee schedule for all code types based on specialty.