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. • Reporting: Prepare and present clear and concise compliance reports to senior management. Required Qualifications Use your skills to make an impact

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. • Participated in Risk Adjustment Data Validation Audits to support program compliance. • Collaborated on vendor performance in respective region, providing timely feedback, analysis and outcomes supporting goals. • Maintained collaborative working relationships with Claims, Enrollment, IT, our essential collaborators, and contracted vendors. • Interpreted data and financial metrics to propose opportunities on strategies to ensure company goals are met. • Demonstrated leadership and diverse teams that oversaw implementation of risk adjustment interventions. • Ensured early detection of major risks and interdependencies to support program success. • Directly responsible for the oversight, hands-on participation, and delivery of large-scale projects/programs. • Organized development of enterprise-level planning and program objective setting. • Provided strategic input on the development of program roadmaps, action plans, work plans, and timelines. • Created a team-oriented work climate that enabled professional development and encouraged creative solutions and strategies. • Ensured communication between the team members, business leaders, and diverse teams. • Influenced other departments to ensure deliverables were accomplished as promised.

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.• Assists in directing the comprehensive pre-delegation review process for new vendors.• Assists the Director in providing delegation oversight reports to appropriate Health Net Committees.• Assists in developing educational strategy for delegated vendors to improve their performance of delegated activities.• Manages staff.• Directs and participates in activities of assigned committees and project teams.• Performs other duties as assigned.

• 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 for management, executive management and the audit committee.• Works with internal and external customers to develop operational reports.Ensure data quality as well as quality of all outgoing reports and analyses.Other duties as assigned.

• Performs necessary investigation, analysis, and evaluation to determine project feasibility. Develops project cost and benefit estimates to establish project worth, including developing alternative considerations leading to recommendations for new systems or equipment installations or changes to existing ones.• 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 relationships towards optimum positive outcomes.• Quality checks outsource vendor deliverables.• Ensures Business System Designs properly address all requirements and do not contain any unresolved conflicts with current system designs.• Assist QA in planning and development of system and integration tests.• Assist QA in reviewing system and integration test results.• Provide systems consulting for business and business engagement.• Plans, organizes, documents, coordinates and schedules all appropriate work in the development of assigned projects/ tasks/ Leads programmers and analysts on the team.• Recommends IT equipment needed for solution of the problem. • Modifies systems designs to make maximum advantage of existing equipment resources.• Determines the operational changes and the new procedures that must be employed to support the new or enhanced system, obtains user management approval for the changes, and develops the user training package necessary to ensure an orderly and efficient changeover to the new system

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.• Provide guidance and support to team members, ensuring they possess a deep understanding of Medicare Part D programs and meticulous attention to detail.• Develop and conduct training sessions to ensure team members are up-to-date with enrollment operations, Medicare membership enrollment, reconciliation, and benefits coordination operations.• Utilize hands-on experience with 834 EDI, State (CA DHS), and CMS files to troubleshoot issues and optimize processes for efficiency and accuracy.• Collaborate with other teams and departments to streamline workflows and improve overall operational effectiveness within the Medicare Advantage Operations team.