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Click here or scroll down to respond to this candidateCandidate's Name
Quality Performance Measurement and AnalysisStreet Address Fall Creek DrLutz, FL., Street Address
PHONE NUMBER AVAILABLEEMAIL AVAILABLEEXPERIENCEIndependent Health, Remote NY HEDIS Medical Record ReviewerJanuary 2024 - May 2024(Temp) Review patient medical records to determine if the quality of care measures are met. Review data sources to determine any incentives or financial rewards for the health plan. Ensure accuracy and address any issues or errors that are found to discuss with the medical providers. Provide quality improvement consulting to improve any issues or errors. Review reports for accuracy of the HEDIS measure collected and get samples ready to be processed by NCQA auditors. Excels sheet of member demographic to research and investigate where to locate medical records, and HEDIS measures have been met within the data sheet. WellSense Health Plan, Remote NH, MASS HEDISMedical Record ReviewerDecember 2022 - December 2023(Temp) Review patient medical records to determine if the quality of care measures are met. Review data sources to determine any incentives or financial rewards for the health plan. Ensure accuracy and address any issues or errors that are found to discuss with the medical providers or vendors. Review reports for accuracy of medical records collection from vendors. Review the claims data source to ensure medical records collection is accurate. Excels sheet of member demographic to research and investigate where to locate medical records, and HEDIS measures have been met within the data sheet. Create a pivot table and charts to present within a weekly meeting to summarize action that has taken place to resolve and meet daily goals.Fontanez Innovative Consultant, Florida HEDIS Quality Improvement ConsultantJanuary 2020 - November 2022(Contract) To work to improve the overall quality of medical or behavioral care that a hospital or other medical practice delivers to patients and families. Educate staff or providers on the correct standards for healthcare procedures which include proper documentation, coding, SKILLSAnalysis System Program:Tableau, Oracle, SAS, SAP,SQL, IBM Cognos Analytics,Sigma.EMR System: Athenahealth,eClinicalWorks, Cerner,Practice Fusion, Allscripts,Kareo, EpicCare, Optum,NextGen, Greenway, andOffice Practicum.Software Programs: AllMicrosoft products, EPIC,Facets, Diamond, Quora,Cotiviti, and Innovation.Health Plan Subject MatterExpert (SME): ICD 10 codes,HCPCS codes, CPT codes, CPTII & CPT III codes, HCCcoding, Medical record reviewand documentation, Brightfutures, NCQA standards,Prior Authorization, Appeals,Appeals audits, Medicalrecords audits, Priorauthorization audits, Healthplan clinical guidelines, Datacollection, HEDIS, CMS,Claims, Billing, Utilizationmanagement, Casemanagement, Behavioralhealth or Mental healthmanagement, Medicationmanagement, Regulatorystate contract, Medicaid,Medicare, Commerical, andall LOB's.Candidate's Name
Quality Performance Measurement and Analysis18205 Fall Creek DrLutz, FL., 33558PHONE NUMBER AVAILABLEEMAIL AVAILABLEbilling and reporting on quality of care. Excels sheet of member demographic to research and investigate where to locate medical records, and HEDIS measures have been met within the data sheet. Create a pivot table and charts to present within a weekly meeting to summarize action that has taken place to resolve and meet daily goals. Review excel sheets from the EMR system and investigate the performance levels and provide solutions or change action plans to provide a successful outcome. Magellan Health Plan, Remote AZ Quality Improvement SpecialistJanuary 2021 - October 2021(Temp) Quality management principles and tools to improve processes, products, and services within the health plan. To maintain quality assurance and improve within the denial and approval processes for utilization management.WellCare Health Plan, Florida Quality Practice Advisor/ Quality Improvement Project ManagerMay 2016 - November 2019Project Manager roles: Serious Mental Illness (SMI) Population, manage HEDIS measures for this population and have quarterly quality improvement committee (QIC) meetings with contracted providers to manage these members or review, change and improve clinical guidelines. Other HEDIS measure projects to improve outcomes were asthma, diabetes, medication management and mental health management.Practice Advisor roles: Educate staff or providers on the correct standards for healthcare procedures which include proper documentation, coding, billing and reporting on quality of care. Review patient medical records to determine if the quality of care measures are met. Provide quality improvement consulting to improve any issues or errors. EDUCATIONUSF Corporate Training & Professional Education, Florida Lean Six Sigma Green Belt CertificationDecember 2023HEALTH CERTIFICATIONBasic Life Support (BLS) -Certificate ID: 01HA643Adults & Pediatrics FirstAid/CPR/AED -Certificate ID: 01G7CVBLANGUAGESFluent in SpanishREFERENCESAvailable upon requestCandidate's Name
Quality Performance Measurement and Analysis18205 Fall Creek DrLutz, FL., 33558PHONE NUMBER AVAILABLEEMAIL AVAILABLEUSF Muma College of Business, Florida Diversity, Equity& Inclusion in the workplace CertificationMay 2021EBC Bushwick High School, New York City High School DiplomaJune 1997PROJECTSHEDIS Projects NCQA Audits (January to May)The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by more than 90 percent of the US health plans to measure performance on important dimensions of care and services. This project is a process to help identify performance gaps and establish a realistic target for improvement. This audit will look into information practices, control procedures, integrity of data, compliance with HEDIS specification, sampling methods, data collection, procedures, analytics file creation and reporting.Measures Projects Data Collection (June to December) Complete a statistical overview of HEDIS measures that need improvement. This project is to improve outcomes by identifying groups that have performance issues or errors within gaps of care. |
