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HEDIS Analyst

Location:
New York, NY
Posted:
June 27, 2018

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Resume:

DWAYNE BREWSTER

** ********* ****** ***. **, Brooklyn NY, 11212

Phone: 561-***-**** Email: ac51l8@r.postjobfree.com

PROFILE: Resourceful, self-starting individual, with an extensive background in the Healthcare Operations, Managed Care, Analytics and HEDIS /QARR in search of a rewarding position with growth potential. Excellent communicator and team-player with superior interpersonal skills and the ability to work with geographically dispersed, diverse, multi-cultural groups.

SUMMARY OF QUALIFICATIONS:

Establish and maintain good working relationships with staff, clients and coworkers.

Demonstrate and model professionalism and maintain confidentiality.

Goal oriented individual with a strong eye for detail.

Effective problem solving, mentoring and training experience.

Assist regulatory and departmental affairs considered necessary by management.

Schedule appointments and perform follow up conformations

Ability to accept responsibilities and delegate where needed

Computer literate & Internet savvy in MS Office

PROFESSIONAL EXPERIENCE:

Quality Practice Advisor: Aeroteck (WellCare) - New York, NY 2017-Present

Recommend provider practices and IPAs in appropriate HEDIS measures, medical record documentation guidelines and HEDIS ICD-9/10 CPT coding in accordance with NCQA requirements.

Team up with Provider Relations to improve provider performance in areas of Quality, Risk Adjustment and Operations (claims and encounters).

Ensure that documentation produced and/or processed complies with state regulations and/or accrediting body requirements.

Ensure assigned contract/regulatory report content is accurate and that submission adheres to deadline.

Document action plans and details of visits and outcomes and reports critical incidents and information regarding quality of care issues.

Deliver provider specific metrics and instruct providers on gap closing opportunities.

Develop, enhance and maintain provider clinical relationship across product lines.

Lead and support collaborative business partnerships, elicit client understanding and awareness to advise and make recommendations.

Provide resources and educational opportunities to provider and staff.

Capture concerns and issues in action plans as agreed upon by provider.

Communicate with external data sources as needed to gather data necessary to measure identified outcomes.

Support quality improvement HEDIS and program studies as needed, requesting records from providers, maintaining databases, and researching to identify members' provider encounter history.

Gather and summarize provider performance data to identify and plan opportunities for provider improvement.

Ensure accuracy in medical records for data collection, data entry and reporting.

Enter documentation of findings in identified databases.

Perform other duties as assigned.

HEDIS Operations: Momentum Solutions (MetroPlus) - Edison, NJ 2016-2017

Assisted drafting, designing and implementing the Quality Operations Manual.

Organize and support medical record retrieval by partnering with onsite medical management staff to coordinate closure of gaps in care through various reconciliation efforts.

Monitor Access databases to ensure accuracy and effectiveness of quality metrics and reporting.

Coordinated and performed remote and onsite medical record reviews to determine compliance with quality metrics.

Clinical Coding Coordinator: Healthfirst - New York, NY 2015-2016

Support chart retrieval activities around Provider Education assignments, which include monitoring confidential information in the appropriate areas of record keeping reviews, including HEDIS and QARR reviews.

Contact provider offices to request and review charts in support of HEDIS & QARR reporting processes.

Periodically travel to provider sites to copy appropriate sections of medical records as directed by management, as well as documenting results and member/provider data points in the given administrative tools, such as MACESS and Excel spreadsheets.

Support coders with entering data pertaining to patient diagnoses, validation results, and analysis.

Utilization Management Service Coordinator: Access Staffing (Healthfirst) - New York, NY 2015

Created personal care aide authorizations and other services for MLTC members quickly and efficiently.

Made changes to service schedule as MLTC member's schedule needs change.

Arrange home care/health services as approved by the director based on medical necessity.

Performed daily departmental activities to ensure productive goals were met in regard to quality, timeliness, and accuracy.

Quality Specialist: Advantage Care Physicians - Brooklyn, NY 2014-2015

Coordinated and performed remote and onsite medical record reviews to determine appropriate coding and billing practices, compliance with quality metrics, and compliance with service delivery standards.

Outreached patients and worked in tandem with care management to maximize outreach for preventive services and chronic disease management.

Educated providers and staff about the QM process, including HEDIS, QARR, STARS, and HCC; along with proper coding and billing practices.

Assisted in defining opportunities for improvement in the continuity of care and implementing programs that will address any gaps in care.

Performed data abstractions on medical records according to specifications and entered them into data collection tool.

Coordinated and performed remote and onsite medical record reviews to determine appropriate coding and billing practices, compliance with quality metrics, and compliance with service delivery standards.

Supported the HEDIS team in staff training, member outreach, preparing and communicating monthly reports, maintaining databases, and data analysis.

Medicare Risk and Revenue Supervisor: Advantage Care Physicians - Brooklyn, NY 2012-2014

Collaborated with coders and the Matrix analytical team to implement the Physician Bulletin program, which helped improve continuity of care for patients by increasing accuracy and completeness of Hierarchical Condition Category (HCC) diagnoses.

Served as the central hub for all HCC bulletins and dissemination to all 8 medical offices for Provider review.

Followed up with medical office Administrators to ensure all bulletins were reviewed, signed, and returned by the assigned provider in a timely manner.

Allocated completed HCC bulletins to designated coder for overview and finalization.

Drafted weekly and monthly reports for coders and medical office administrators to facilitate reconciliation of all outstanding bulletins.

Assisted charge entry specialist with posting charges and claims.

Call Center Representative: Advantage Care Physicians - Brooklyn, NY 2011-2012

Analyzed data and used cognitive skills to make responsible decisions during appointment scheduling and other patient service requests.

Assisted patients with any questions regarding the organization and resolved calls with minimal outside direction by researching and exploring answers, alternative solutions, implementing solutions, and escalating unresolved problems.

Maintained applicable call center database by entering and/or amending information.

EDUCATION:

Strayer University West Palm Beach, FL Major in Business

Deighton Griffith Secondary Barbados, West Indies High School Diploma



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