🔹 Formalize Standard Operating Procedures to improve service provision and consistency.🔹 Streamline workflows to improve staffing communication.🔹 Consolidate business assets, determine financial viability, assess merger and acquisition potential.

🔹 Managed and performed full cycle retrieval projects for new clients including point of contact, overall implementation project management, acquiring client data, closely monitoring project status and outcomes throughout the entirety of the project (RADV, HEDIS, ACA, MRA).🔹 Contributed to the development of a joint company strategic account planning process that developed mutual performance objectives, financial targets, and critical milestones resulting in stronger operational outcomes.🔹 Assisted with the functional design of new software applications (i.e., coding platform meeting client-specific requirements) to align with client needs and ensure growth.🔹 Clearly communicated the progress of project initiatives to internal and external stakeholders.🔹 Identified opportunities in collaboration with the sales team to ensure growth (i.e., social determinants of health metric collection, gap closure, meeting metrics for respective projects).🔹 Monitor new process (i.e., how the clients was supposed to submit data for upload into the system, tech specs to follow and abide by) and technology initiatives (i.e., social determinants of health, KPI specification, technology use) to ensure alignment with client needs.🔹 Experience in leading, managing and collaborating in a matrix environment.

🔹 Promoted to provide strategic training and compliance expertise to ensure strong program growth under state contracts, earning an Impact Award for Compliance Risk Assessment. 🔹 Developed and implemented quality improvement plan in accordance with the mission and strategic goals of the organization, federal and state laws and regulations, and accreditation standards.🔹 Identified best opportunities including practice implementation of data-driven population health strategies and operational efficiencies, resulting in increase in membership engagement and closure of gaps in care.🔹 Ensured consistent compliance with Corporate, Department of Medicaid Services & Quality Improvement work plans.🔹 Participated in the development, management, review and reporting of program outcomes for clinical quality programs, including implementation of learning collaboratives, webinars, toolkit enhancement, local strategy.🔹 Assisted with quarterly Performance Improvement Projects, led department projects, and mentored staff in matrix environment.🔹 Routinely presented Department of Medicaid Services.🔹 Served as Interim Director for 5 months to ensure consistent leadership.

🔹 Planned and implemented centralized call center operations: created SOP for new system, wrote manuals, charted workflows, developed Q&A system, designed and used tracking tools, compiled lessons learned.🔹 Staffed and oversaw 100 employees through COVID pandemic (and ensuing staff reduction of 20%), maintaining a volume of 4k calls/week and exceeding goal of 85% retrieval of medical records.🔹 Made decisions about resources and operations related to HEDIS reporting, collaborated cross-departmentally to ensure high standard of deliverables, monitored progress and created process improvement for future implementation.

🔹 Reviewed and negotiated Delegated Vendors' contracts.🔹 Participated in the onsite 2019 CMS Compliance Program Effectiveness Audit, performed oversight of business audit preparation to ensure timely, accurate and complete submission of required data and documentation to regulators.🔹 Provided compliance guidance, direction, and risk assessment to assigned business partners and stakeholders.🔹 Determined staffing needs, raises and bonuses for staff of 8-10 people; oversaw projects and initiatives within department, including tactical operations and resource allocation.🔹 Developed and implemented compliance policies and procedures: researched compliance issues and recommended changes that assured compliance with regulatory and contractual obligations. 🔹 Conducted periodic compliance reviews of business partner operations, and coordinated implementation and compliance with corrective action plans, as needed.

🔹 Focused on large and Model Practice Medicare groups (Value Based Providers) to help support the transactional side of the business, ensuring accurate setup/processing/rules, monitoring changes.🔹 Initiated, planned, and framed process improvements for providers and established requirements while consulting and gaining commitment from all key stakeholders (external & internal).🔹 Established strong provider partnerships and built relationships with internal stakeholders to create a seamless experience for providers; collaborated cross-functionally to support cost efficiencies and quality improvement.🔹 Assisted with Provider Payment Integrity resolution management, claims management, resolution for per member per month, and STARS gap closure.🔹 Engaged Providers in Action Plans to increase quality and cost efficiencies, focused on large-scale provider groups.🔹 Collaborated cross-functionally to support cost efficiencies and quality improvement.

🔹 Hired to analyze markets, products and contracts to drive revenue enhancement for the East Central Market. 🔹 Created synergies with other departments to collaborate on business initiatives and deliver analytical reports. 🔹 Streamlined processes to create reporting efficiencies and expedite analysis. 🔹 Developed analytical report structures for the provider groups to assist with HEDIS gap closures and STAR initiatives and increase engagement. 🔹 Showed ability to quickly adapt to new software and systems to integrate business functionality. 🔹 Recognized for outstanding customer service.🔹 Conducted analysis of Disease Population Waterfalls to enhance participation in Clinical Management Programs.🔹 Conducted Impact Analysis related to Emergency Room, Urgent care and PCP visits.🔹 Worked with the clinical areas to develop more automated reports for customer reporting and operational decision making.🔹 Created queries from a database to pull specific information and collected multi-faceteddata, analyzing the information to make recommendations.🔹 Developed dashboards and metrics to drive provider group engagement and STAR ratings.

🔹 Generated and analyzed multi-faceted data using advanced methodologies and tools. 🔹 Identified trends, recommended process improvements, and assisted in the presentation and implementation of recommendations and solutions. 🔹 Served as a Subject Matter Expert and representative of the organization during the implementation of new systems, tools, and processes that impacted the business.🔹 Created and presented Business Case Justifications and recommendations for claims processing. 🔹 Collaborated with other business areas for the purpose of improving internal processes and creating a better Provider experience.🔹 Recognized issues with global impacts and helped to facilitate resolution.

🔹 Assessed and monitored the documentation and coding data submitted on claim/encounters for Medicare Risk Adjustment in the Puerto Rico market. 🔹 Role included training and serving as a resource on coding procedures and appropriateness to providers, provider office staff, other MRA team members, and other corporate/market departments.🔹 Interacted and consulted with Spanish speaking providers in Humana's markets with regards to diagnosis codes, encounters and medical records (CMS, HEDIS).🔹 Updated the policies and procedures for the Bilingual retrieval specialist.🔹 Reviewed and handled a high volume of claims/encounter data based on the MRA reports. 🔹 Assisted with verifying the accuracy of diagnosis information submitted on claims/encounters for the purposes of risk adjustment. 🔹 Demonstrated problem-solving ability in analyzing and identifying issues or problems with submitted diagnosis codes to actual services provided to the patient. 🔹 Evaluated and made recommendations regarding office work flow. 🔹 Provided data, assistance and acted as a resource to the Medicare Risk Adjustment team, external business partners, other markets, and internal associates. 🔹 Developed quality improvement plans for outliers as appropriate. 🔹 Identified, prioritized, and provided training and served as a resource on coding procedures and appropriateness to providers, provider office staff, other team members, and other corporate/market associates. 🔹 Supported and participated in process and quality improvement initiatives. 🔹 Consistently recognized opportunities, communicated them to the appropriate parties, and eliminated barriers and non-value added activities to improve the overall work system in examining patient care data.

🔹 Responsible for increasing sales in Louisville, Indiana and Ohio market.🔹 Tasked with overseeing client applications process and received information from the finance department regarding credit limits and contract negotiations.🔹 Procured customer orders via phone, fax, or in person.🔹 Used creative problem solving to ensure customers were using the product that best suited their businesses as well as their needs.🔹 Prepared presentations and communication materials on behalf of the sales team.🔹 Corresponded with internal and external stakeholders to ensure the successful completion of all projects.🔹Worked closely with Customer Service Call Center to ensure orders were being captured correctly.

🔹 Coordinated filing of applications and petitions, translation of foreign documents, and equivalency evaluations of foreign degrees.🔹 Researched availability of foreign documents and immigrant and non-immigrant visa alternatives.🔹 Drafted applications, petitions, letters and affidavits.🔹 Acted as a liaison for the firm’s clients in both English and Spanish.🔹 Juggled multiple projects on tight deadlines covering numerous diverse areas.🔹 Maintained client and firm files and records as well as client privacy and confidentiality.🔹 Effectively communicated with clients about what steps would be taken to try to solve their problem.🔹 Performed legal research and drafted legal memoranda regarding personal injury, bankruptcy and immigration law.