Project Manager Health
Resume:
Ophelia Aguirre
POB ****
Orange, Ca *****
**************@*****.***
Summary:
** ***** ** ********** ********** for enterprise level projects and initiatives with healthcare payer and provider companies in the Southern California area.
Experienced with performing research and tracking in regards to the Affordable Care Act (ACA).
Knowledge and work process of Obamacare.
Experience with health plan audits that included 201 member counts for auditing of chronic HCC codes for prep and submitting to assigned vendors for chart retrieval and coding.
Extensive documentation. Manage, analyze, strategize, create, improve and implement new operational processes across various function areas of Medicare Risk Adjustment including the submission of claims, provider education, data analysis and audits, data management that includes vendor management oversight and processing of Risk Adjustment Attestations for CMS audit submissions including Risk Adjustment Data Mining efforts within HCC reconciliation project efforts.
Technical Summary:
MS Office Suite: Project, Access, Excel, SharePoint, PowerPoint, Word, Outlook, EZ-CAP, IDX, Encoder Pro, Caremark,
Ascender, Health Risk Partners, EPIC, 3M, Cerner, CDAT, NextGen, Cerner and Care Connect.
Education:
Lean Six Sigma training program (ongoing until 3/17)
Certified Risk Coder (prepping for exam)
Certified Coding Specialist (prepping for exam)
Registered Health Information Tech (attending online)
Professional Experience:
Manager, HEDIS, P4P, Stars
Synermed – Los Angeles (FTE) October 2016 - Present
Manage a team of 12 within a HEDIS department
HEDIS Staff training
HEDIS Provider Staff training
Prioritize HEDIS measures for gaps in care
Created action plan and task list
Identify supplemental and non-supplemental data for submission
Managed performance measures for annual HEDIS reporting
Monitored HEDIS data collection, conduct data analysis, coordinate medical record review, outreach activities
Created Policy and Procedures for all hybrid measures
Project Manager Quality Managements Risk Adjustment
UCLA Faculty Group – Los Angeles (Contract) January 2016 – October 2016
RAF/HCC/RADV/HEDIS/STARS/CMS/AWE Optimization Projects.
Identify gaps and implement interventions to improve results.
Medicare Advantage member’s opportunity score reporting.
Reconciliation reporting to match up with the database in ensuring all your encounter data is submitted.
Perform investigative research with thorough understanding of measures.
Work Clearinghouse Rejections and ICE files to submit additional DX codes or deletes.
Audit EZ-CAP for correction of diagnosis and procedure inconsistencies.
Project Manager/Analyst
Keck Medical Center of USC - Irvine, CA (Contract) October 2014 - September 2015
Assemble, develop and refines/improves the key operational components necessary for multiple concurrent initiatives with shared services, USC Keck operations, Information Technology, health plan and external partners.
Research, tracking of Affordable Care Act (ACA) and collaborate analyze findings.
Worked on the eligibility and enrollment modules to update the platform for the USC patients.
Build a common model for operating all programs with internal and external experts to identify and analyze for gaps improvement opportunities.
Created and executed specific deliverables and activities within the Cerner and NextGen database.
Updated database with ICD-10 modules for proper medical billing and coding.
Crosswalk education to medical staff on proper ICD-10 Coding for HCC Risk Adjustment.
Update EZcap practitioner contractual agreements to reflect CMS Medicare contracts.
EZ-CAP implementation of ICD-10 HCC risk adjustment.
Project Manager/Analyst
OPTUM Insight- Santa Ana, CA (Contract) October 2013- October 2014
Project Manager/Coordinator for an enterprise initiative of over $35 million dollars.
Project Managers, a Project Coordinator, and 400 resources both on-site and remote supporting the project.
Work with project coordinator in managing two health plan audits that included 201 member counts for auditing of chronic HCC codes for prep and submitting to assigned vendors for chart retrieval and coding.
The Work flow processes were managed by MS Project and submitted to the Optum executive team by Power point presentation for reporting to the Health Plan for the results.
CMS RADV contract-level audits for HCCs, submit results through CDAT for CMS Medicare Advantage Review the quality of risk adjustment data submitted for payment by MA organizations.
Determine beneficiary risk scores/risk –adjusted reimbursement on enrollee diagnosis, as specified by ICD-9 CM to prospectively adjust capitation payment for a given enrollee based on health status.
Develop using Medicare fee-for-service claims data to identify HCC risk score for each enrollee.
Review and auditing of claims for proper diagnosis being captured on EZ-CAP.
Performance Program Administrator
Prospect Medical Group- Santa Ana, CA October 2011 - October 2013
Monitor MMR/MOR reports for HCC data.
Manage health plan data validation projects (RADV, STARS, P4P, and HEDIS).
Complete corrective action plans upon request by Health plan.
Identified HEDIS and STAR Ratings for Quality and RX measures that follow NCQA and CMS documentation guidelines
Analyze and track lost revenue from chart review/suspects/ Part D/homebound/AWE.
Work with network providers for general risk adjustment education.
HCC/HEDIS Analyst (Contract) 2nd Job
MD Care Health Plan- Long Beach, CA June 2011 - October 2011
Reviewed and identified high risk diagnosis codes as probable suspects from HEDIS measures.
Extracted HEDIS effectiveness of care measures for Commercial/Medicaid/Medicare members for NCQA’s HEDIS performance measures.
Project Analyst (Contract) 2nd Job
DATAFIED - Anaheim, CA February 2010 - March 2010
Chart review of HCC coding sweep project, managed remote coding team and HCC reporting of analytical data.
Manager, Risk Adjustment
Arcadian Health Plan - San Dimas, CA August 2007 - January 2010
Extract, analyze HCC risk adjustment and ICD-9 data for CMS sweeps.
Develop, implement and review coding compliance from physician clinical documentation, risk adjustment reports and applications from outside vendors.
Manage and oversee HCC department staff (clinical coding auditors, independent contractors, external vendors).
Responsible in assuring that all pertinent clinical information impacting the risk scoring of members is captured and transmitted to CMS, Conducted educational coding classes for network providers and clinician staff.
Manage CMS/RADV audits for readiness and insured all process and criteria are in compliance for CMS submission.
Focused on members with multiple chronic illnesses and incorporate the best practice in intensive case management, disease management, behavioral health and care coordination for high risk and high cost patients through individualized care management.
Proactively developed and updated policy and procedures for risk adjustment in compliance to CMS.
Manager, Reimbursement Specialist
St. Joseph Health System- Orange, CA January 2001 - August 2007
Managed inpatient/outpatient charges, posting, and billing and collection operations, ensured accurate and timely billing was in compliance by staff members.
Supervised procurement insurance and financial obligation information on patient’s ability to pay for treatment and coordinate with credit/collection staff members on evaluation of patient’s benefits and review of applicants to determine free care allocations and programs.
Monitored activity reports with collection agencies, admitting, third party approvals and indigent programs.
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