Quality Management Consultant, Provider Relations Liaison

DARLA MAY

Quality Management Consultant, Provider Relations Liaison

HEDIS Reviewer/Abstractor

Mailing Address: 7155 W. Broken Oak Circle Southaven, MS 386**-***-*** 6561

acpy4d@r.postjobfree.com

Having just completed the 2015 HEDIS project as Quality Management

Consultant for a major health plan I am looking to relocate to the

beauty of California (or other coastal/mountainous states) once a solid

but challenging position in healthcare is acquired. I have thoroughly

enjoyed traveling to physician offices and clinics performing nationally

mandated reviews and audits such as HEDIS, however the down time

between required Reviews is a drawback. My desire is to function in a

capacity that allows me to draw on the knowledge and experience

gained throughout a 20 year healthcare career, from direct patient care

in Memphis area pediatric and psychiatric hospitals during my first

decade of medical employment to attaining expertise in medical billing,

claims management, including the particulars associated with

Medicare, Medicare Advantage HMO’s and PPO’s, Medicaid, Tricare,

commercial carriers and Work Comp, to most recently specializing in

quality improvement measures. Along with the valuable first hand

experience acquired over nearly two decades I have been fortunate to

grow and develop in both a personal and professional manner, utilizing

tools obtained from each unique employment opportunity. A continual

thirst for knowledge drives me to research areas of particular interest

such as key aspects of the Affordable Care Act and initiatives affecting

individual and small group practices. This innate desire to learn

combined with a natural empathy for others make me an ideal

candidate for the position of (Quality Management Consultant, Provider

Relations Liaison). As one who invests deeply into my clinical role, I

have functioned for years as a patient advocate and as such am quite

adept as a liaison, motivator and problem solver. In addition, my work

in quality improvement/performance based audits utilizing standards

set by NCQA and other national regulatory agencies has prepared me

for analytical investigations while maintaining strict compliance with

accepted mandates and local protocol.

I am single and career oriented maintaining flexibility in my work

schedule and have organized my affairs aiming for a “start date” of

June 8, 2015. I thank you for your time and would welcome the

opportunity to assure you that I am indeed your best candidate!

DARLA MAY

Quality Management Consultant, Medical Records/Billing Specialist

HEDIS Reviewer/Abstractor

Mailing Address: 7155 W. Broken Oak Circle Southaven, MS 386**-***-*** 6561

acpy4d@r.postjobfree.com

Recent Experience:

US Tech Solutions (professional staffing service) Jersey City, NJ

Current Employer, beginning Dec. 2014

QM Consultant

Consultant for major health insurer covering Southwest TN for 2015 HEDIS

project. Schedule onsite visits to medical offices. Work with physicians,

practitioners and staff to identify applicable performance measures utilizing

technical specifications set by the National Committee for Quality

Assurance (NCQA), abstract pertinent data and enter into client's

proprietary data base. Review measures with physicians, identify strengths

as well as potential deficiencies and gaps, when asked consult with staff

regarding methods of more precise evidence based documentation,

Available post review to assist with practices still utilizing paper charts in

setting and achieving goals for quality improvements, enhancing staff

participation in precise disease specific charting. Upon request, assist

providers in researching EMR systems effective in achieving meaningful

use objectives. Available to assist in conversion process and educating

staff regarding NCQA specifications, setting goals to close gaps and

incorporating simple measures to improve patient satisfaction as well as

clinical outcomes.

Physicians Data Services Memphis, TN Nov. 2013 Feb. 2015

Medical Billing/AR Specialist

Charge Entry, Payment Posting, Claims Management and follow up with

Commercial carriers,Tricare, Medicare, Medicaid, Medicare Advantage

Plans, HMO's, PPO's and setting private payment arrangements, Work all

rejections & denials to decreased aging accounts. Performed complete

billing and AR Management for 6 individual, Memphis area physicians.

Maintained excellent communication with physician and administrative

personnel to ensure consistency and accountability. Created positive

relationship with patients via phone and internet, acting both as patient

advocate and liaison for provider, improving patient/provider

communication and accessibility, resulting in improved self pay

reimbursements, decreased delinquent accounts.

Outcomes Health Information Alpharetta, GA Aug. 2011 May 2013

Medical Record Field Reviewer/Data Retrieval & Abstraction

Travel throughout MS, TN, AR, KS to medical offices, outpatient clinics and

hospitals performing onsite medical record reviews for HEDIS, Payment

Integrity, Risk Assessment, retrieve designated data, scan into laptop and

upload to proprietary data base. Establish positive business relationships,

assist physician and administrative staff in understanding practice specific

performance measures and familiarize with NCQA standards.

**Submitted suggestions to corporate office related to issues encountered

in the field and possible methods of problem resolution. Was subsequently

flown to Corporate to meet with company CEO and conduct meetings with

various department heads educating each on the actual role of a Field

Reviewer, identifying both positive and negative aspects of face to face

interactions with providers and staff. Spearheaded open discussions with

representatives from each department which resulted in numerous quality

improvement initiatives

Unified Health Services Memphis, TN Dec. 2008 – Aug. 2011

Workers’ Compensation Specialist

Total management of Workers’ Compensation claims for several

Occupational Health and Urgent Care clinics throughout TN, MS, AR, VA,

NY and MA

Handled initial billing of work comp claims, follow up of any rejections or

denials by appeals and reconsiderations in addition to phone contact with

employer, patient, case manager and carrier CSR’s. Initiated appropriate

pre authorization requests and second opinions for surgeries. Handled

small percentage of OWCP, Department of Labor claims.

Education:

Horn Lake High School Horn Lake, MS

Received Diploma May, 1978

**Graduated to 10% of class, Honor Society, Beta Club, Who’s Who

Among American High School Students (1977 78) Athletic Scholar Award

1978

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