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Click here or scroll down to respond to this candidateCandidate's Name
Professional SummaryHealthcare professional with 8+ years experience with HEDIS/Data abstractionResponsible for data collection, abstraction, and over-reads for company quality improvement performance measuresLead data collection, abstraction, and over-reads for company quality performance measures, including HEDIS, Adult and Child Core Set and other custom measuresWorked with HEDIS team to collect member recordsConducted reviews/over-reads of records to determine if record meets HEDIS criteria and/or was reviewed correctlyReviewed, created, uploaded, and researched spreadsheets to provide updated dataEnsured documentation completed with 110% accuracyPrepared correspondence and reviewed documentation for conformance with internal policies and proceduresMaintained files, ordered supply, coordinated meetings, and compiled and distributed meeting minutesAdvanced knowledge of Microsoft Office (Word, Excel, PowerPoint, Outlook) HEDIS, Change (Altegra) Health Alert Portal, CIOX, HUI-Q, QSHR, Gateway, GRITS, GAHIN, EPIC, Affinity, NextGen, ICD-9, and ICD-10, DATAVANT, OPTUM, Amisys, Centene ConnectAvailable to interview with 24-hour noticeLives in Atlanta, GA looking ideally looking for hybrid work conditionsProfessional ExperienceCentene, Peach State Health Plan12/2023 5/2024Quality Improvement CoordinatorReferenced NCQA Education and Training Resources, NCQA Quality Measures for HEDIS dailyResponsible for data collection company quality improvement performance measures utilizing Datavant, OPTUM, Amisys, Centene ConnectLead data collection and for company quality performance measures, including HEDIS, Adult and Child Core Set and other custom measuresConducted reviews of records to determine if record meets HEDIS criteria and/or was reviewed correctlyPlaced the results collected intospecific data baseHandled telephonic interaction with provider offices/memberAssisted with the development andcoordination of all core health servicesFollowed NCQA guidelines06/2022 12/26/2023DCM Program Coordinator / Program Coordinator (Inbound / Outbound Calls)Outreach 60-70 daily PSHP Members and complete Assessment/Screening assigning Members for Telephonic or Digital Case Management utilizing WellframeCommunicating detailed information for Members understanding of Case Management and PSHP servicesUtilized TruCare, Interpreta, Impact Pro and GAMMIS to identify Members claims, eligibility, providers. DOS. Procedures and engagementsInstruct, answer and discuss any questions or concerns for members on how to download Wellframe ApplicationCreate Case, Task, Referral to assign Members a Case Manager BH or PH, and HROBAnswer Inbound calls to address callbacksProvide written and oral communication using TEAMS, Outlook, Avaya - TelephonicallyReview claims for DOS, procedures, diagnosis, IP, ER, OP, psychological and dental visitsDuring receipt of call verify HIPAA Identifiers a minimum of three out of five11/2021 5/2022Quality Improvement CoordinatorResponsible for data collection, for company quality improvement performance measuresLead data collection for company quality performance measures, including HEDIS, Adult and Child Core Set and other custom measuresWorked with HEDIS team to collectmember recordsConducted reviews of records to determine if record meets HEDIS criteria and/or was reviewed correctlyPlaced the results collected into aspecific data baseHandled telephonic interaction with provider offices / membersprovider offices/membersAssisted with the development andcoordination of all core health servicesFollowed NCQA guidelinesProgressive Insurance6/2021 11/2021Customer Care RepresentativeResponsible for answering and forwarding 60 calls per day utilizing Avaya Phone SystemProcessing personal injury claims for insured and claimants, agents, and law officesUtilizing SoClr software, Microsoft Teams, Outlook, Avaya CommunicationCentene Arkansas Health &Wellness Plan3/2021 5/2021Quality Improvement CoordinatorResponsible for data collection, and over-reads for AR Health and Wellness Plan quality improvement performance measuresLead data collection and over-reads for company quality performance measures, including HEDIS, Adult and Child Core Set and other custom measuresUtilized QSHR researching for alternate chasesSubmitted SR Tickets when applicableWorked with HEDIS team to collect member recordsConducted reviews/over-reads of records to determine if record meets HEDIS criteria and/or was reviewed correctlyPlaced the results collected into a specific data baseHandled telephonic interaction with provider offices/membersAssisted with the development and coordination of all core health servicesFollowed NCQA guidelinesUnitedHealth Group1/2019 3/2021Project CoordinatorSupervised and trained to research claims and DOS utilizing iSETUpdated data, checked and maintained all chases including scheduled, unscheduled, active, pends, and overdue chases in RateLiftChecked and reviewed received medical records in OnBaseEntered QSHR working with various projects to research and locate alternate providers for all measuresCommunicated utilizing Jabber, IM, Outlook, WebEx, and WordReviewed, created, uploaded, and researched spreadsheets to provide updated dataEnsured documentation completed with 110% accuracyInteracted with team members, providing assistance and knowledgeUtilized References in QSD Education & Training Resource Center, NCQA Updates Quality Measure for HEDIS, 2018 Tech SpecsResearched VTB to resolve and correct alternate chasesUtilized Change Alert Healthcare Portal reviewing compliant and noncompliant measures, review entered communication and locate providers and alternate providersFaxed medical record request utilizing RightFax and e-FaxCompleted required training and Learning Source coursesPinnacle Technology - UPS7/2019 3/2020Pricing SpecialistReviewed and maintained all Add/Deletes and Conflicts AccountsReviewed Addendum, Amendments, and Implementation Checklists with Corrective WorksheetsEntered data in Enterprise and SPPQRS Analyzers with 110% accuracyCompiled and maintained weekly Bid Expiration Report for over 500 accountsExtended Bids as necessary and review for extended processUtilized IAS, DWH. BIA and Workflow, Share drive dataCommunicated and interacted with 20 Enterprise Account Managers and DirectorsCommunicated utilizing Jabber, IM, Outlook, WebEx, and Word.Reviewed, created, uploaded, and researched spreadsheets to provide updated dataEnsured documentation completed with 110% accuracyInteracted with team members, providing assistance and knowledgeUtilized Reference books, Notes, Weight and DIM guidance for accuracy utilizing Rate Chart GuideCompleted required trainingCentene Peach State Health Plan1/2017 10/2017HEDIS CoordinatorEnsured HIPAA guidelines met using three out of five identifiersOutreached 60-70 Providers, Vendors and Members daily via telephone discussing medical records and/or care managementInterpreter requested as needed to assist with communicationResponsible for data collection for company quality improvement performance measuresDiscussed Care Management with PSHP MembersLead data collection for company quality performance measures, including HEDIS, Adult and Child Core Set and other custom measuresWorked with HEDIS team to collect member recordsConducted reviews of records to determine if record meets HEDIS criteria and/or was reviewed correctlyPlaced the results collected into a specific data baseHandled telephonic interaction with provider offices/membersAssisted with the development and coordination of all core health servicesFollowed NCQA guidelinesIron Mountain3/2016 8/2016Image Processor and Release Information SpecialistResearched and resolved customer issuesModified work procedures as needed to meet customer demandManaged project timelines, quality, and outcome of customers ordersProvided accountable standards and measures to the department employeesPerformed time studies for Sales/Account ManagementAbility to assist in the invoicing processAmazon11/2015 5/2016Part-Time Fulfillment AssociateWrapped packages for shippingSorted and scanned package to package and ensured destination deliveryInspected wrapping of pallets for safety to dock and deliveryUtilized pallet jack to move pallets to correct destinationsStudied and followed the OSHA guidelinesCleaned and secured the working area and environmentTrained and instructed employeesFollowed instructions and provided assistance as neededSeparated packages for lane deliverySorted small packagesAnthem6/2014 8/2015Administrative AssistantProvided customer service to all customersResponsible for providing high level administrative support to an individual or departmentResearched and verified information pertaining to reportsPrepared/tracked budgetsCreated databases and analyzed moderately complex dataSupported projects by assisting manager/department, built and maintained project plans, scheduled and contributed to meetings to ensure project deliverables are metPrepared correspondence and reviewed documentation for conformance with internal policies and proceduresMaintained files, ordered supply, coordinated meetings, and compiled and distributed meeting minutesHandled travel arrangements and expense reportsScreened, handled, or distributed incoming calls and complaintsBlueCross BlueShield4/2008 5/2014RHIT HEDIS Quality Project Coordinator ContractorVerified members HMO, PPO, POS and Medicare plansUsed customer service skills while assessing patientsWorked with HEDIS GuidelinesDaily reviewed ICD-9, ICD-10, CPT, HCPCS codesTrained and instructed 3-4 employees utilizing Pursuit Tool, MRRS, Mediconnect, BCBS QCare and Microsoft WordSearched compliance for members using Medical Record ReviewContacted and spoke daily with office medical staff and physicians in medical facilitiesReceived and obtained member information to be reviewed by National Committee for Quality Assurance (NCQA) for the HEDIS ProjectUtilized Pursuit Tool entering data and specificity for each medical office recordEntered data in Excel spreadsheet and fax documentationPracticum11/2010 5/2011Health Information Technology InternshipUtilized five (5) Medical Facilities Portals including McKesson-Med Host VP, CISCO, SSL, VPN downloading Medical Records to process claims using FOB security keysUpdated addressees in Centricity - IDX Billing SystemReviewed and processed EOBs, COBs, and medical records for commercial insurance and workers compensation claimsReviewed documents for accuracy; update informationAware of and maintained confidentiality utilizing the HEDIS, HIPAA, JCAHO, JCO and PHI regulationsReviewed documentation and completed in a timely manner with 99 percent accuracyFamiliarity with tabular, alpha, and procedural codes using ICD-9, ICD-10, CPT, HCPCS and MS-DRGEducationAtlanta Technical CollegeAssociates Degree in Health Information TechnologyAtlanta Technical CollegeMedical Coding CertificateBooker T. Washington High SchoolHigh School Diploma |
