Maintain compliance with all regulatory laws and standards through reporting, training of staff, and implementing various compliance and quality improvement initiatives⋅ Design and implement programs, policies, and practices to ensure State and Federal program contract compliance, as well as compliance with federal and state legal and regulatory requirements.⋅ Coordinated and supplied HEDIS Road Map sections 1-7 to national and state auditor on time.⋅ Created a combined Appendix 1 and General Information to understand how measures are reported across the organization.⋅ Directed and managed cross functional teams to streamline methodology around processing benchmarking documents from auditors as well as uploading IDSS XMLs,⋅ Help facilitate Frozen Count to insure MRR validation is done accurately and within the deadline.⋅ Create process around patient level detail (PLDs) to understand any discrepancies with uploading them after the dry run with NCQA is over.⋅ Work with the CAHPS team to understand requirements for submissions.⋅ Issue Log items from auditors were answered within time and logged for quality improvement.⋅ Manage and support the Healthcare Organization Questionnaire (HOQ) for over 42 different organizations.⋅ Analysis process and understanding of impact report to our rates. SSOR and ECDS DAV certified sources.⋅ Managing newly introduce tool for supplemental data to track and streamline communication across all lines of business for inquiries and new sources.

Organized and supported Medicare team with the migration of Inovalon (QSI) to Verscend (Cotiviti) with downstream enhancements to the “Gap in Care Report” to provide additional value to Medicare states throughout Anthem.⋅ Managing newly introduce tool for supplemental data to track and streamline communication across all lines of business for inquiries and new sources.⋅ Developed an inventory of supplemental files to normalize data and establish strategic framework for corporate objectives and audit support.⋅ Training & 1:1 time with Anthems associates in new roles both internal and enterprise wide.⋅ Supporting all regional data managers for Medicare requirements by attending and serving as primary POC for provider group and large hospital systems by working to resolve issues, brokering solutions to allow for data to be consumed for scorecards, HEDIS rates and IDSS submission.⋅ Provide logic and oversite to consolidate and profile Roadmap Section 5 ’s for Medicare, Medicaid, and Commercial for HEDIS compliance auditors (HSAG Aqurate Metastar DTS Attest) to ensure data integrity with a completion of over 533 sources standard and non-standard.⋅ Provide responses to all audit questions and demonstrate to auditors’ data structure to ensure accuracy.⋅ Work with hl7 CCDA CCD vendors with their non-standard data, DAV certifications and data requirements.⋅ Presented to leadership the impact dashboards of supplemental data branded by data type to evaluate and improve performances of data feeds for all lines of business.⋅ Validating rates for Commercial and Medicare line of business to ensure data integrity before release.⋅ Evaluate workflows to understand potential gaps in processes and messaging to maximize transparency across the organization.⋅ Coordinate and host weekly team meetings on assorted topics to assure productivity and remove barriers.⋅ Ensure compliance with all related regulations within the company for quality assurance

 Implement a provider incentive payment system (MPIP) for Molina Florida with state mandated reports being met on time.  Developed an outreach tool in order to reduce cost and improve health through preventive care while cleaning data through multiple touch points. Analyze preventive visits and ER utilization to identify effectiveness for care management teams. Produce SSRS reports to find data barriers and improve process in multiple departments.  Improved W15 measure by 30% by producing a systematic process approach. Project rate increases across all HEDIS measures by analyzing population trends.  Manage programmers in several data bases including QNXT to recover paid claims. Categorize disease management groups and develop benchmarks in order for a chronic care model to prosper.  Organize data in a way convenient for dimensional analysis by creating a data cube with Inovalon (QSI).  Create comprehensive workflows for the production and distribution of assigned reports; document reporting processes and procedures Generate and distribute standard reports on schedule using SQL, Excel, and other reporting software Collects and documents report / programming requirements from requestors to ensure appropriate creation of reports and analyses. Analyze data sets and trends for anomalies, outliers, trend changes, and opportunities. Assist with completion of special projects as requested by various internal departments, or in support of requests from regulatory agencies, contracting agencies, or other external organizations Performs research and analysis of complex healthcare claims data, pharmacy data, and lab data regarding network utilization and cost containment information.  Evaluates, writes, and presents healthcare utilization and cost containment reports and makes recommendations based on relevant findings.

 Manage the data, process, and training necessary to generate and understand the metrics involved with HEDIS set by NCQA Develops and identify new supplemental data sources for use in HEDIS reporting Oversee the progress and productivity of services rendered for Medicaid, Medicare, and Marketplace Evaluate team performance and project status to develop a strategy to reach NCQA benchmarks and thresholds in order to decrease state sanctions and liquidated damages  Maintain adequate staffing infrastructure and support for altering projects Supervises continuous quality management and utilization improvement activities Development of targeted communications and marketing materials to educate providers and members Provide functional and technical knowledge for NCQA/HEDIS across departmental staff and provide educational sessions/training Established teams to implement interventions to increase HEDIS and CAHPS scores focusing on state quality measures counting towards withhold and star measures Monitor the creation of all project deliverable's to ensure adherence to standards and the support the project life cycle including requirements gathering, creation of project plans and schedules manage resources and facilitate project execution, deployment and closure Developed formal lines of communication between health plan personnel including providing information, instructions and directives in order to attain cooperation and fulfill health plan objectives Drove results through continuous quality improvement for all lines of business Supervised collection of statistical data as needed, developed statistical reports and drew conclusions used by program planners and managers in administrative decision making Worked with data analysis team to establish database for bench-marking clinical performance and outcomes

 Responsible for the investigative analysis of 7 HEDIS measures including W15, W34, AWC, CIS, IMA, Lead Screening and CAP  Participate in the Medical Record Review processes to emphasize on critical HEDIS abstraction guidelines Understanding population trends in Medicaid, Medicare and Marketplace to support behavioral interventions  Develop member and provider participation methodologies based on data interpretation to promote healthy behavior Provide recommendations and train internal departments on the application of HEDIS guidelines for proactive quality improvement  Conduct an ongoing data abstraction, validation and analysis, based on the monthly/quarterly missed services reports Gathered and synthesized data from multiple sources in order to produce accurate and timely reports; distribute reports for internal and external users (QNXT,CCA, QSI, Palantir)

 -Analyze, develop, implement and monitor clinical Quality Improvement initatives to achieve healthy outcomes; supporting Molina, HAP, Total Health Care, BCN, BCBSM and Priority Health. -Provide education and consultation to providers’ and provider practice sites in regards to the National Committee for Quality Assurance (NCQA) HEDIS measures.  -Perform duties and functions within the ACO to comply with quality improvement programs according to CMS requirements in the Medicare Shared Savings Program. -Gather and synthesize data from multiple sources in order to produce accurate and timely reports; distribute reports for internal and external users (e.g. MIPCT, ECP). -Performed onsite chart abstractions of care providers medical records, and other associated medical-field materials, at remote locations in the metro Detroit area. -Facilitate the use of Electronic Medical Record (EMR) or Electronic Health Record (EHR) in order to organize and maintain patient health history.  -Operate Michigan Data Collaborative (MDC) dynamic dashboards to enhance analysis of multi-payer claims data, enable actionable care plans, and monitor and improve quality measures. -Lead PGIP initiatives as well as organization activities to implement PCMH standards.

- Managed and oversaw an $800K new construction build out of our current retail facility, which involved four different contractors simultaneously. Project was finished on time and within budget.- Select and coordinate all new store inventories to meet fluctuating retail demand, which increased sales approximately 30%.- Maintain all supplier relationships to ensure the forecast accuracy of just in time inventory to meet store demand on a daily basis.- Develop supplier processes to streamline products to market, which also helped drive standardization and improve productivity.- Adhere to ownership’s annual budget to maximize store profit while meeting retail demand.- Mentored over 60+ new staff while encouraging a team environment to promote employee confidence.- Trained and supervised over 15 employees, whose jobs include harvesting fields, transport operations, receiving docks, stocking inventory and workers who interact with the customer experience through the retail check out.