JORGE A. FLORES RODR GUEZ

*** ****** ** ********

Guaynabo, Puerto Rico 00966

787-***-****

787-***-****

acdq13@r.postjobfree.com

SUMMARY OF QUALIFICATIONS

. Over fifteen years of knowledge and experience in the Health Care

Management, both in physical and mental health scenarios.

. Trained and experienced professional in the Puerto Rico Health Care

Reform and Medicare laws, rules and regulations applicable for

Medicare Advantage.

. Project Management Director of Risk Adjustment optimize premium for

Medicare Advantage Health Plan.

. Project Management Director of IPA's Utilization Analysis.

. Project Management Director of Transitional Care Management Program.

. Experienced in negotiation and establishment of fees.

. Feasibility Study's

. Participation in the human resources initiatives to improve employee

engagement, talent management and employee relations.

. Participation in Joint Commission Accreditation Process

EDUCATION

Graduate Certificate in UNIVERSITY OF

PUERTO RICO

Gerontology Medical Sciences

Campus

Graduate

School of Public Health

June, 2004

Master of Health Services UNIVERSITY OF

PUERTO RICO

Administration Medical Sciences

Campus

Graduate

School of Public Health

June, 2002

Bachelor in Sciences UNIVERSITY OF

PUERTO RICO

Cayey Campus

June, 1985

PROFESSIONAL EXPERIENCE

CompCare, Puerto Rico, Inc.

December 2011- December 2012

MBHO Operations Director

a. Develop, implement, monitor and ensure the proper coordination of

daily operations.

b. Coordination of all activities and plans with all Health Plan related

areas to implement the project and meet health plan corporate goals.

c. Participation in the human resources initiatives to improve employee

engagement, talent management and employee relations.

d. Responsible of Claims and Providers Departments.

e. Perform reconciliation Amount charged to Medicare Advantage claims.

f. Conducting Health Clinics

g. Provider's contracts for the network, including Hospitals.

Quality Healthcare Management

September 2005- Present

Consultant

Project Director.

a. Transitional Care Management Program.

b. Participation in the human resources initiatives to improve

employee engagement, talent management and employee relations.

c. Develop, implement, monitor and ensure the proper coordination

of daily operations.

d. Financial Analysis.

e. Evaluate data, trends and results.

f. Utilization Analysis

g. Presentations

h. Other Projects

Feasibility Study's

a. Internal Analysis: Client Business Perspective

b. External Analysis: Competitors

c. Define Options: Analysis of Business Based on Options

d. Define Ranking Criteria & Score

e. Feasibility Study Report

f. Participation in the human resources initiatives to improve employee

engagement, talent management and employee relations.

Project Manager Director: Risk Adjustment Project to optimize premium.

a. It includes the coordination of all activities, and plans with all

Health Plan related areas to implement the project and meet health

plan corporate goals.

b. Identify gaps in the Risk Adjustment processes and methodologies and

provide recommendations to Health Plan management team.

c. Assist Health Plan management team in the development and

implementation of risk adjustment strategies to meet the Premium

Optimization Goal.

d. Establish the relationships with providers (physicians, specialties

and facilities) and coordinate appointments with them to obtain the

medical records needed for risk adjustment processing.

IPA's Utilization Analysis in Medicare Advantage and Puerto Rico

Health Care Reform

a. Services and Pharmacy Claims Data Analysis

b. Statistics: Evaluate data, trends and results.

c. Development and establishment of protocols; policies, procedures

and operational actions with the IPA's Medical Director for Cost

Contention strategies.

d. Presentations for IPA's providers: Utilization and Incentive Reports

Healthcare Management: Physical and Mental Health

a. Process Analysis

b. Proposals

c. Strategic Planning

d. Negotiates with the third party payers

e. Joint Ventures in Health Care Reform with third party payers

f. Coordinate with clients professional services contracts.

g. Providers contracts for the network

h. Liaison between the third party payers and the providers.

i. Billing and collection of medical plans

j. Conducting Need Assessments

k. Conducting Reengineering studies

l. Conducting studies at hospital institutions

m. Audit billing process

Emergency Department Director and HIMA Surgicenter Director

November 2003- August 2005

1. Responsible for the organization, administration and the adequate

operation of different areas of the department.

2. Review and develop a plan of correction for the deficiencies found by

the inspectors of the accrediting agencies and assure the same are

corrected.

3. Participate in the evaluation, selection and integration of technology

and management information systems that provide support to the needs

of patient care.

4. Participate in the planning and implementation of optimum quality

services in accordance with the Medical Director of the department.

5. Analyze production data of the department to visualize tendencies,

process deviation and concerns of patients to determine cause and

correct these.

6. Develop, together with the Environmental Committee of Care, Program of

Security, Fire and Disaster; assures an adequate management of

patients in the implementation and during the duration of emergencies

and evaluates the obtained results.

Operational Director and Administrator, Hospital Buen Pastor

Abril 2003-October 2003

1. Participate as active member of the Administrative Medical Board and

submission of protocols for their approval; as well as serving as liaison

for any event and/or situation.

2. Prepare and document organization's strategic plans.

3. Serve as coordinator between Medical staff, Administrative Medical

Board, Executive Director and Board of Directors.

4. Coordinate daily operations along with the Executive Director.

5. Supervise daily operations.

6. In coordination with the Finances Director, maintain and guarantee

economic stability of the institution.

7. Prepare annual budget.

8. Develop and maintain an effective public relations' program for the

institution.

9. Serve as an active member of the Safety and Security, Quality control,

and the Control of Infectious Diseases Program's committees.

10. Participate in Board of Directors' meetings.

11. Establish and Implement rules and regulations and policies for the

personnel, with the previous approval of the Board of Directors.

Associate Administrator, Mennonite General Hospital, Cayey

November 2001- March 2003

1. Coordinate administrative and managerial activities at the hospital,

with special attention to the Emergency Room Unit.

2. Coordinate managed care with hospital clinical staff on a 24- hour

shift and every other weekend.

3. Evaluate function of the different departments.

4. Keep and assure physical facilities' quality and safety.

5. Promote and assure effective communications with the medical faculty.

6. Compliance Officer

RESEARCH SUBMITTED, PUBLICATIONS AND PRESENTATIONS

. Reingenier a del Proceso de Pruebas Diagn sticas de Radiolog a en el

Hospital Y (August 2002).

. Reingenier a del Proceso de Admisiones Pedi tricas en el Hospital de la

Universidad de Puerto Rico en Carolina (May 2001).

. Estudio de Necesidades en el Municipio de Juncos (October 2001).

. Percepci n de la Facultad M dica del Hospital X con respecto al Proceso

de Admisi n (August 2001).

. Planificaci n Estrat gica en Atlantic Medical Center en Manat , Puerto

Rico ( March 2001).

. Medicare: Contrataci n de facultativos para Sala de Emergencia.

Presented at the Menonita General Hospital for the Medical staff.

(August 2002).

. Asistencia y Presentaci n de un tema. Presented at the Menonita

General Hospital for the clinical staff as part of the course-

Mejoramiento de Calidad. (March 2002).

. Medicare Plus Choice: Laws and Regulations. Presented at the Menonita

General Hospital Board of Director's Meeting. (January 2002).

. Special Project: Hyperbaric Medicine. General Concepts, DRG and

reimbursement, medical insurance covered, Billing Requirements and

Payment Requirements. Presented at the Hospital Interamericano de

Medicina Avanzada de Caguas, Operational Committee Meeting.

(December, 2003).

. Medicare: Medicare Prescription Drug, Improvement and Modernization

Act of 2003 (Pub. L. 108-173). Presented at the School of Pharmacy, as

a continued education (December 2004).

. Medicare Concepts Presented at the School of Public Health, as a

conference in Administrative Aspects in Gerontology (2004-2012).

. Puerto Rico Health Care Reform Concepts Presented at the School of

Public Health, as a conference in Administrative Aspects in

Gerontology (2004-2012).

. Medicare: Medicare Prescription Drug, Improvement and Modernization

Act of 2003 (Pub. L. 108-173). Presented at the School of Pharmacy, as

a continued education (December 2004).

. Reforma de Salud y las Personas de Edad Avanzada. Presented at the

"Primer Simposio de Gerontolog a en Puerto Rico, Del Discurso a la

Acci n" (October, 2006).

. Medicare and Puerto Rico Health Care Reform Concepts Presented at

Ponce's School of Medicine, as a conference in the Graduate School of

Psychology (April and June, 2008).

COMPUTER KNOWLEDGE/COMPETENCE

. Excellent Analytical Skills.

. Experience in auditing Medicare and Health Care Reform Claims.

. Knowledge in Word for Windows, Excel, SPSS, Epi-Info, Sabiamed &

HMO Medical Auditor.

. Experience in manipulating high volume of data.

. Excellent Power Point presentation Skills

OTHER INFORMATION

Languages

. Spanish and English

Contact this candidate