Human Resources Project Manager
Resume:
JORGE A. FLORES RODR GUEZ
Guaynabo, Puerto Rico 00966
*****.***@*****.***
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
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