In charge of all Prominence Health's Encounter and Supplemental data submission to CMS, this role presents an incredible opportunity to deepen my knowledge of the CMS Risk Adjustment and HEDIS Quality program.Building on my experience in data collection and performance improvement, I will now focus on the critical phase of data submission to ensure the highest CMS acceptance rate possible. This transition aligns perfectly with my career goal of gaining a comprehensive understanding of the entire Risk Adjustment lifecycle.

Advisor #1 - Healthcare Consulting and Analytics

In charge of Risk & Quality operation, including Field operation and Analytics. My goal is to drive efficiency, elevate performance, and contribute to TECQ Partners ongoing success in delivering cutting-edge Risk & Quality solutions to our Patients, Providers, and Payers.Achievements:Complete redesign of Medication Adherence dashboard to make it easier to use, and truly actionable for TECQ provider offices.Cost / RAF Dashboard - combining multi-years Claim data, which helps Tecq leadership team targets opportunities to save cost, consider auditing, and define scope to maximize value of future chart-chase projects.Quality Dashboard - integrating multiple sources of data: HealthPlan data, Claims and Supplemental data to calculate performance for CMS STARs and Internal Quality program (PQIP) measures.Project Dashboard - displaying progress and outcome of Chart chasing & coding projects. Calculating ROI, including numbers of Dx & Px coded, net-new & unique HCCs captured per chart, RAF increased. Extract member list can also be used as chart-review guide, with open gaps that need to be closed for each member.Risk Adjustment Dashboards - Calculate Build-up RAF and Funding RAF. Display relationship between HCCs captured, RAF scoring and Funding (Capitation); with ability to drill-down vertically (from PCPs / Groups to Member-level) and horizontally (Year-over-Year, Month-over-Month).

Define, maintain and update coding workflow. Ensure coding practice and clinical data collection compliant with regulations and audits.Keep track of coding productivity, accuracy and completeness.Collaborate coding team activities with other departments in a strategic manner.Provide Coast’s IPA clients with intuitive reports to keep track of their progress.Manage submission of IPAs’ Supplemental Data to all Health Plan clients based on each HP’s required data format: Blue Shield, Alignment, Aetna, Anthem, Easy Choice, Health Net, Humana, LA Care, SCAN, and Optum ASM.Analyze Claims data (837 Professional) and match with Supplemental Data to find opportunities to improve performance for the Risk Adjustment and Healthcare Quality program.Key Achievements:Successfully led QIP team through the ACO GPRO reporting, and P4P Audit seasons.Designed comprehensive Strategic Department Database.Built meaningful Coding and Quality Reports which facilitate senior leadership decision making.Designed a compact and effective Medical Records Logging system for storing and retrieving records.Integrated coding outcome into Department Annual Wellness Visit (AWV) Incentive program.

Review and code medical records, focusing on the Risk Adjustment (HCC) and STAR program.Query physicians and train office staffs to improve medical records documentation, billing and coding.Train and supervise new coders.Key Achievements:Improved and maintained department coding guideline.Designed comprehensive tool sets for the Risk Adjustment and STAR/ACO/P4P programs.

Collect and audit medical records.Review charts regarding HCC and STAR measures, onsite and remote.Improve clinical documentation through queries, feedback and training for providers.Key Achievements:Presented in key universities and forums for group providers and office managers training.Create progress reports and presented in board meetings.

Manage multiple STAR measures projects: COL, ABA, BCS, COA, CDC...Supervise Quality and Member Outreach Coordinators.Build detailed reports that facilitate Medical Director decision making.Key Achievements:Contributed in building “Diabetes Management Program” for high risk Diabetic members. This program helps members better control their blood sugar (HbA1C) and get proper diabetic care.

Emergency Room - Cardiac Surgery ICU - Cardiology Department