Manager Medical
Resume:
Rochelle T. Smith, LVN, CCC, CCA
Downey, CA 90240
Mobile - 562-***-****
Home - 562-***-****
e-Mail: *******.**@*****.***
PROFESSIONAL OBJECTIVE
Seeking a position of responsibility in healthcare that will utilize my
extensive organizational, nursing, and electronic data management skills,
with potential for continued professional growth with an emphasis in
Managed Care.
SUMMARY OF SKILLS
Certified Clinical Coder
Proficient in HEDIS data collection
Competent in Complex Case Management
Competent in Transition of Care Oversight
Certified Clinical Auditor
Proficient in HCC identification and processing
Competent in Risk Adjustments
Strong knowledge of regulatory requirements
CAREER GOALS
Currently studying for the CPHQ exam
WORK EXPERIENCE
UCLA Medical Group / Los Angeles, CA
Quality Management Manager 4/13 -
Present
. Currently responsible for the management of the Quality Management
Department, Provider Relations Department, Credentialing Department,
Member Services Department, Appeals and Grievance Unit.
. Responsible for the development and implementation of departmental
policies and procedures
. Responsible for the day to day operations of the entire Quality
Management Department
. Responsible to ensure compliance with NCQA, CMS, DMHC standards
throughout department
. Develops provider trainings and educational materials which aid in
quality measure compliance
. Oversee HCC documentation, RAF score and coordination by conducting
provider trainings, education and interventions for HCC and RAF score
documentation
. Responsible for HEDIS, CMS Star, and IHA P4P Interventions and reports
deficiencies or recommendations to governing body.
. Acts as Liaison between Departments regarding Quality issues,
participates in CMS and ICE discussions attends workshops and
conferences relating to Quality Improvement, HEDIS or NCQA.
. Responsible to ensure timeliness in provider credentialing for both
initial credentialing and re-credentialing
. Responds to provider issues
. Conducts QM Staff meetings and facilitates staff retention initiatives
. Manages 17 direct reports with the ability to bring in additional
staff when need arises
. Responsible for managing department budget
Datafied Medical Record Consultants
HEDIS Consultant 2/2013 -
6/2013
. Acted as a consultant abstracting and reviewing HEDIS member records
remotely for compliance
Q-Mark Consultants 2/2012
- 6/2012
HEDIS consultant
. Acted as a consultant abstracting and reviewing HEDIS member records
remotely for compliance
Brand New Day / HMO California / Signal Hill, CA
1/10 - 4/13
Quality Improvement Manager
In an HMO setting,
. Manages Appeals and Grievances, Transition of Care, Complex Case
Management, and Medication Reconciliation Units.
. Acts as Liaison between Departments regarding Quality issues,
participates in CMS and ICE discussions attends workshops and
conferences relating to Quality Improvement, HEDIS or NCQA.
. Responsible for complete oversight and leading of HEDIS, medical
record, and NCQA audits and workgroups.
. Assisted in the Design and Implementation of the Quality Improvement
Incentive Program (Token Economy), Wellness Program, Transition of
Care, and the Medication Reconciliation Program.
. Responsible for HEDIS Interventions and reports deficiencies or
recommendations to governing body.
. Responsible for provider peer reviews and medical record audits and
policies and procedures relating to Quality Improvement.
. Develops Pre-Delegation and Delegation audit and scoring tools.
. Responsible for HEDIS, NCQA, STAR measures, P4P, Quality Improvement
Studies (CCIPs and QIPs) and HOS survey submissions.
. Responsible for the coordination of the Quality Council, Executive
Session, Provider Education and Encounter Data Processing and MOCQSI
meetings.
. Oversee HCC documentation, RAF score and coordination by conducting
provider trainings, education and interventions for HCC and RAF score
documentation.
. Responsible for Reporting Sentinel events and Quality of Care Issues.
. Oversees delegation oversight activities including the performance of
pre-delegation and annual audits of contracted medical groups/IPAs'
as appropriate.
. Confirmed presenter at National ICE Conference.
. Reports Directly to Executive Vice President of Operations /
Compliance Officer
California Institution for Men in Chino, CA / Chino, CA
3/07 - 1/10
LVN / HIV Case Manager
. In an acute setting provided direct assistance to physicians, custody
staff, patient and nursing staff.
. Managed a case load of up to 120 patients at one time. Arranged
appointments, ensured physician orders were carried out and patients
received required supplies, scheduled follow-up appointments, met with
providers regarding critical cases, and provided daily, weekly and
monthly reports to supervisors.
. Performed medical chart audits, interviewed patients upon admission to
facility, participated in patient/family educations, maintained
patients medical chards and ordered supplies,
. Responds to patients complaints, assisted in resolving any patient
complaints
. Performed nursing duties including physical assessments, direct
patient care, recognized life-threatening situations and initiated
life-saving measured, performed treatments and medications,
documentation and other nursing functions as necessary.
Braswell's Colonial Care / Redlands, CA
6/06 - 3/07
LVN / Charge Nurse
. Provided direct assistance to physicians, patient and nursing staff,
maintained patients medical charts, maintain and ordered supplies,
answered multi-line phone system.
. Responds to patient's complaints, process physician orders.
. Performed nursing duties including physical assessments, direct
patient care, participated in patient/family education, recognized
life-threatening situations and initiated life-saving measures,
performed treatments and medications, IVs, documentation, and other
nursing functions.
LTC Risk Consulting Services / Glendale, CA
12/05 - 3/07
Risk Consulting Services Coordinator / LVN
Support Risk Management consulting services in all activities which
included:
. Provides proactive loss prevention and control consulting services to
single and multi-site long term care companies
. Assist with Policy and Procedure review, revisions and distribution
. Assists in the implementation of the Risk/Quality Program throughout
long-term care facilities.
. Strong knowledge of regulatory requirements including Title 22, DHS,
NCQA, JACHO/Joint Commission and others as required, assists in
maintaining regulatory compliance by attending public policy
conferences and staying informed of new regulations and laws.
. Works closely with various departments and organizations,.
. Acts as mediator for all company's commercial lines of insurance,
Process clinical incident reports.
. Assists in education of clients on Risk Management services, Performs
clinical audits for clients, Assists in reviewing medical record
documentation.
. Design, maintain web-based database, Maintains department efficiency
in operations, Manages office and responds to queries in directors
absence and various tasks as assigned by Director.
Lakewood Regional Medical Center / Lakewood, CA
4/05 - 12/05
Unit Secretary / LVN
. Provided direct assistance to physicians, patient and nursing staff,
maintained patients medical charts, maintain and ordered supplies,
answered multi-line phone system.
. Responds to patient's complaints, process physician orders.
. Performed nursing duties including physical assessments, direct
patient care, participated in patient/family education, recognized
life-threatening situations and initiated life-saving measures,
performed treatments and medications, IVs, documentation, and other
nursing functions.
Visiting Angels of Riverside County / Riverside, CA
8/04 - 4/05
Caregiver / Companion
. Assisted with activities of daily living like grooming, dressing and
toileting, assisted in preparation of meals, accompanied clients to
physicians appointments and documentation of daily procedures.
4 D College / Colton, CA
10/03 - 10/04
Clerical Assistant
. Assisted Placement Coordinator in various aspects including but not
limited to data entry, filing, answering multi-line phone system,
scheduled meetings, transcribing meeting minutes.
. Assisted students with placement issues, designed spreadsheets.
. Other clerical duties as assigned by Placement Coordinator.
Universal Care, Inc. / Signal Hill, CA
8/97 - 5/03
Risk Management Coordinator (3/99 - 5/03)
. Provided direct assistance to the Director of Risk Management and also
to the corporate Medical Records Department, Employee Health Manager,
Patient Safety Manager and Risk Management Project Coordinator.
. Provided assistance to the following committees: Forms Committee,
Company Forms Letter Committee, Privacy Committee, Third Party
Liability Committee, Risk Management Committee, assisting with
policy/procedure development and distribution, overseeing the School
Affiliation Program.
. Assisted in the overall development and implementation of the Quality
Management Department including payroll duties.
. Strong knowledge of regulatory requirements including Title 22, DHS,
NCQA, JACHO and others.
. Managed and completed school contracts, processing insurance
Certificates, assisted in completion of insurance applications for
company.
. Investigated fraud and abuse complaints,
. Processed risk referred issues, set up and closed case files,
designed, archived and maintained access database, archived previous
years risk referrals
. Produced monthly and year-end statistics, organized and documented
project meetings
. Coordinated HIPAA Privacy Training and assisted in implementation.
. Performed Medical Record Auditing and Oversight, recorded and
transcribed meeting minutes
. Maintained department efficiency in operations, managed office and
responded to Queries in the Director's Absence.
. Medical Assistant, Women's Health Department (8/97 - 3/99)
Run reports, data entry; answer multi-line telephone, office supply
ordering, general office filing, faxing, photocopying, perform nursing
procedures,
. Assist Physician with back office procedures, take vital signs, give
injections, use autoclave, telephone triage, schedule appointments,
verified insurance eligibility, keep rooms stocked and clean,
documentation in Patients charts, patient teaching, accepted co-
payments and processed incoming patients.
CERTIFICATIONS & EDUCATION
Certified Clinical Coder / 2010
Certified Clinical Auditor / 2010
Certified RCFE Administrator / 2006
Vocational Nursing Program / 2003 - 2004
4D College / Colton, CA
Medical Assistant /1997 - 1998
Bryman College / Gardena, CA
General Studies / 1994 - 1997
Oakwood College / Huntsville, AL
COMPUTER SKILLS
Skilled in Microsoft Office Products, Microsoft Excel, Access, PowerPoint
as well
as customized Medical Database Programs
REFERENCES
Available upon request
Contact this candidate