Yamilet Truex Email & Phone Number

Remote

• Manage team of direct reports in creating innovative new analytical concepts for Medicare and ACA Risk Adjustment within Veradigm's Risk Adjustment Analytics and Risk Mitigation products, focusing on condition gap opportunities, MYRA/FYRA financial accuracy, ACA transfer payment strategies and innovative intervention planning.• Triage, assign and assist in customer inquiries for deep-dive data analyses.• Perform critical-to-quality analyses of customer data and P8 analytics to ensure high-quality and accurate results. Including trending large data sets over time to distinguish anomalies quickly and thoroughly.• Serve as the subject-matter-expert for Medicare/ACA RA guidance and staying up-to-date on latest regulations, including ACA Edge ICD and BRDs, MA Advance and Final Notices, HPMS memos etc.• Oversee team members time and project allocations, sprint planning, quarterly priorities, and assisting in shifting when needed.• Perform sales demonstrations for prospective customers on the value and innovation P8 offers.• Project manage large scale initiatives, coordinating various teams across the organization, ensuring requirements are documented, creating project and testing plans etc.• Provide training and mentorship at various levels for staff and customers on RA concepts and strategy.• Develop business cases and requirements for new products and current product enhancements.• Serve in Scrum Master role in prioritization of development work following SAFe/Agile practices. • Own customer financial improvement modeling and engaging directly with current or new customers to update models.• Lead research initiatives to monitor P8 algorithm performance over time and recommend future enhancements.• Collaborate with clinicians in outcomes, algorithm performance, and new product development.

Remote

• Assist team of data scientists, researchers, risk adjustment experts, and developers in leading business cases for algorithm development and improvement, researching customer queries of analytics performance, creating requirements for new analytics and data products, and working in tandem with data teams in executing these requirements.• Perform in-depth, detailed data analyses for customers, including claims, enrollment, pharmacy, lab data and government files (Medicare MMR, MOR, RAPS Returns, MAO, ACA Edge RARI, RARSD, RARCSD etc,).- Monitor critical-to-quality data validation to ensure data integrity by seeking out anomalies in customer data files, trending norms and coordinating cross-teams for resolution.Keep up-to-date with all CMS/HHS guidelines for ACA and Medicare RA submissions, risk scoring and model updates.• Act as company subject-matter-expert, supporting training, guidance, and strategy for customers and more junior staff.• Work closely with developers and engineers on business requirements, unit and regression testing for new enhancements and bug resolution.• Work closely within an Agile structure and collaborate with teammates for innovation of new algorithms.• Design new analytical concepts for Risk Adjustment Data Validation (RADV) software (Valid8) including identifying scenarios and conditions at higher risk for audit failure. Identifying and establishing propensity scale for conditions with higher risk for improper clinical coding or documentation.

Cleveland/Akron, Ohio Area

• Responsible as a primary data analytics and reporting expert for Medicare Government Operations, including enrollment, appeals and grievances.• Provide leadership and guidance to more junior level staff in the use of reporting tools and identifies areas for improvement in data mining and analytics.• Provide triage and oversight of data analytics requests, assigning of projects/tasks to appropriate staff and monitoring of progress towards to deliverables. • Monitor and evaluate departmental processes and leads improvements. • Resolve highly complex issues through the reconciliation of large data sets. • Present complex materials to all levels of management and ensures that it is easily consumed by various audiences, including executive leadership. • Oversight of enrollment monthly reconciliation activities, including the discovery, reporting and resolution trending of discrepancies in various business processes such as enrollment, Low-Income Subsidy (LIS), Late-Enrollment Penalty (LEP), Medicare Secondary Payor (MSP), End-Stage Renal Disease (ESRD), MMR payment adjustments, member demographics and others. • Business process owner for monthly premium billing activities for Medicare Advantage members, including validation of LIS, LEP and other discrepancies impacting direct member invoicing. • Partnering closely with business operational analysts, managers and staff to seek out root cause for discrepancies, process improvements and regulatory guidelines. • Responsibility over department regulatory reporting; ensuring SQL programming and program documentation is in line for regulatory audits, including Part C/D Annual Reporting (Enrollment/Disenrollment, ODR, and Grievances), Data Validation Audit, Program Audit, Appeals Timeliness etc. • Develop quality control reports and programs to audit data integrity to ensure data elements are in compliance with government guidance.

Cleveland/Akron, Ohio Area

• Responsible for defining all required reporting and frequency for government programs both within health plan and clinical operations. • Design, develop and implement new reporting policies, procedures and submissions as it relates to government regulated plans by the Centers for Medicaid and Medicare (CMS) and Health and Human Services (HHS).• Manage data transmission programs including Medicare Risk Adjustment (RAPS/EDS), CMS (HPMS) and (ACA) Edge Server.• Defining, designing, data collection, analytics, quality review and submission of all regulatory reports to federal and state agencies such as Medicare Part C/D annual reporting, Medicare and Commercial Risk Adjustment and CMS plan connectivity secure FTP transfers etc. • Production of health plan analytics for both Medicare and Commercial Risk Adjustment including attribution of Hierarchical Condition Categories (HCCs) through various model scenarios, future risk score forecasting and trending. • Complex programming and monitoring of ACA Edge Server submissions. Creation and monitoring end-to-end from source system extraction, normalization across multiple systems, transformation to HHS compliant regulations through to error management and submissions to Edge Server. • Management of varied direct and indirect reporting staff including full time employees, team leads and individual contractors.• Overall project management responsibilities including work plan development, establishing timelines, budgetary compliance and tracking milestones to ensure regulatory and financial deadlines are met. • Provide analytical assistance and information to clinical operation areas such as providers, clinical coders, physician billing and clinical leadership. • Extensive experience in complex data sets crossing issuers, plans, payors and contracts.

Cleveland/Akron, Ohio Area

• Organize and maintain processes for the submission of data for Medicare risk adjustment.• In depth knowledge of complex transition system planning, data governance and normalization. • Responsible for the design, creation and extraction of data from multi-platform source systems for submissions to CMS Risk Adjustment Processing System (RAPS) such as Oracle, SQL SSMS and Teradata data stores. • Project management and analytical oversight of submissions through CMS Encounter Data Processing (EDPS).• Responsible for organizing collaboration of government regulations with claims processing, membership administration and clinical operations for optimal diagnosis capture and claims submissions. • Collaborate with multi-regional teams, trouble-shoot and perform analysis on complex data spanning several years. • Project manage complex changes to CMS rules and implementing across programs to ensure compliance and functionality. • Develop reporting tools to monitor volume, trending, reporting scores and reports etc. Evaluate anomalies, issues and errors. Develop resolutions, project guidelines and timelines. • Subject matter expert for the organization on risk adjustment guidelines and risk scoring attribution.

Cleveland/Akron, Ohio Area

• Primary role to provide leadership over conversion project to ICD-10 Diagnosis Code billing for the organization’s Ohio region. • Leadership over regional team (business project managers, IT project managers, testing leads, organizational readiness teams etc.).• Experience with working within national and regional program management structures.• Coordinate project issues between both business and IT to establish priorities, ensuring the timely implementation of deliverables. • Evaluate and assign staffing resources as well as managing local project budgets and accruals. • Contribute in developing alternative solutions and assesses the ability to meet business objectives. Resolve specific issues (policy changes, staff requests, project delays, etc.) and other issues including providing escalation to sponsors and/or national program management.

Cleveland/Akron, Ohio Area

• In depth knowledge of revenue cycle operations and systems, with a focus on providing technology solutions in revenue cycle planning, system issue resolution, workflow development, and associated staff training.• Promote and support billing and collections system functionality and identify best practices including observing trends and inconsistencies in system use and provide feedback to management to identify opportunities for improvement in quality and productivity. • Certified to perform changes in Epic Resolute Professional Billing as administrator. Extensive awareness of all data sources and system triggers that are impacted by system changes and downstream impacts. • Provide expertise in Epic Resolute PB end-to-end data flow and revenue cycle processes. • Initiate and track progress for correction of reported systems problems, enhancements, or changes. • Prioritization of outstanding work requests and act as intermediary between IT and business operations. • Build tools and analytical reports utilizing Crystal Reports, SQL, Business Objects and Microsoft Office utilities to optimize operations and prioritize initiatives.• Project management responsibilities including creating project plans, budgets, resource allocations, requirements and business cases. • Extensive experience in managing multiple projects simultaneously with dynamically changing requirements such as government regulations and system transitions. • Create moderate to complex databases and reports for Revenue Cycle departments, including technical writing in SQL and Visual Basic.

Cleveland/Akron, Ohio Area

• Create, maintain, trend and distribute business operation reports used by management to monitor backlog, measure performance against established goals and identify areas of concern. • Create tools to assist staff in compiling and transmitting data. • Ability to work with large amounts of technical data, identify and resolve anomalies. Develop new processes for check-out organization and offsite service charge capture. • Create training materials and provide staff training on Epic charge capture and check-out process.

Cleveland/Akron, Ohio Area

• Reception duties including check-in, telephone services and direction. Cashier responsibilities including acceptance of co-pay fees and monthly dues. Customer service responsibilities.• EMR coding responsibilities including accessing patient records, entering appropriate billing codes (ICD, CPT) and updating pertinent electronic medical records in both Epic and legacy systems. • Collecting coding productivity and quality assurance data. Communicating results through reports, graphs, and other office utilities.