Heather Milam Email & Phone Number

• Leadership & Strategy: Provide guidance and leadership to the Medicare Risk Adjustment compliance team. Develop and implement strategic compliance plans to ensure adherence to all regulatory requirements.
• Compliance Oversight: Oversee the management and execution of Risk Adjustment Data Validation (RADV) audits, ensuring compliance with CMS guidelines.
• Policy Development: Develop and maintain comprehensive policies and procedures related to Medicare risk adjustment activities.
• Training & Development: Design and conduct training programs for internal teams to enhance understanding of compliance requirements and practices related to Medicare risk adjustment.
• Risk Assessment: Conduct regular risk assessments to identify potential areas of compliance vulnerability and risk; develop/implement corrective action plans for resolution of problematic issues.
• Stakeholder Engagement: Collaborate with internal departments, including the Law Department, to coordinate compliance activities and resolve issues.

Woodland Hills

• Collaborated with the VP of Risk Adjustment to develop a clear strategy with important performance indicators.
• Analyzed qualitative and quantitative data to identify missed opportunities, prevalence, and suspects related to risk adjustment.
• Assisted end-users in gathering reporting requirements and analyzed internal reporting tools.
• Developed ad hoc reports and presentations for risk adjustment projects.
• Oversaw outreach efforts on Risk Adjustment Education based on review of pre-selected charts coupled with data management, data analysis, and provider scorecards.
• Presented HCC/RAF performance results and findings to important internal leadership.

Woodland Hills

• Provides direction of the delegated oversight activities to ensure Health Net's Risk Adjustment Vendors are in compliance with Contracting Agreements, Health Net's Operations.
• Manuals and regulatory agencies.
• Monitors performance and measures results of delegated activities for vendors.
• Identifies improvement opportunities of the delegation and oversight process.
• Provides analyses and summaries of delegated oversight.
• Measures vendor compliance with corrective action plans developed to improve performance.

• Manages staff workload and deadline requirements; prioritizes and allocates resources; hires, trains, evaluates, disciplines, and motivates assigned staff.
• Coordinates the Medicare Part C and D Data Validation audit between internal and external customers.
• Analyzes regulatory data reporting and validation requirements including, but not limited to: Medicare Part C and D Data Reporting and Validation, CMS Star Ratings and Risk Adjustment requirements.
• Provides instruction and guidance to internal clients regarding regulatory data reporting and validation requirements.
• Develops, tracks, and validates corrective action plans related to regulatory data reporting and validation.
• Prepares objective, accurate and factual formal and informal audit reports summarizing the results of regulatory data reporting and validation audits, determining effect and properly assessing and communicating risk.

• Performs necessary investigation, analysis, and evaluation to determine project feasibility. Develops project cost and benefit estimates to establish project worth, including developing alternative considerations.
• Develops conceptual designs and/or feasibility studies for proposed computer-based systems that satisfy the identified user needs and are compatible with the user and IT environments.
• Gathers and documents project business and IT specifications/requirements for infrastructure and application development projects.
• Partner with business/IT resources to ensure BARR quality and completeness.Acts as liaison between business and application/infrastructure outsourcing vendors. Ability to effectively handle and manage vendor.
• Quality checks outsource vendor deliverables.
• Ensures Business System Designs properly address all requirements and do not contain any unresolved conflicts with current system designs.

Woodland Hills, CA

• Lead and supervise a team responsible for processing all enrollment, disenrollment, and cancellation requests within Medicare Advantage programs.
• Ensure accurate completion of enrollments in accordance with CMS and other Managed Care Guidelines.
• Oversee the processing of all Enrollment, Disenrollment, cancellation requests, reinstatements, and managed retro reconciliation files or requests.
• Supervise the reconciliation of daily Transaction Reply Report (TRR) and retro reconciliation files.
• Maintain oversight on the accuracy and timeliness of acknowledgment notices sent to members.
• Foster and maintain open lines of communication with various departments to resolve member issues promptly and implement ADHOC resolutions to sustain quality member care.