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Medical Quality

Location:
Dallas, TX
Posted:
May 12, 2020

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Resume:

Krishna D. Shorty, MHA

*** ***** ** ******, ** 75208

Phone: 414-***-**** Email: adc6s1@r.postjobfree.com

Healthcare Professional /Quality Improvement

Passionate, dedicated, and motivated professional with a strong healthcare quality improvement experience; developing, implementing, monitoring and analyzing appropriate quality improvement projects. An exceptional background in Organizational Leadership and Healthcare administration Management, with working Knowledge of HEDIS reporting, Abstraction database collection and documentation, as well as Medicare Star rating. Possess a Master’s degree in Healthcare Administration as well as years of successful experience working in fast-paced clinical environments and facilitating positive relationships with a wide range of patients, colleagues, team members, and other key partners in the healthcare community. Consistently recognized for outstanding contributions and commended for efficiency, priority management, and communication skills. Computer savvy and familiar with many modern systems and software applications including MS Office Suite.

Areas Of Interest

Healthcare Management

Patient Relations

Knowledge of SQL

Administrative Support

Planning & Scheduling

Records Flow

Strategic Operations

HIM

Healthport

HEDIS/STAR

Data Entry & Reporting

Technology Integration

Regulatory Compliance

Budgeting & Cost Control

Training & Team Building

RateLift

QSHR System

Documentation Imaging System

Ciox Health

CAHPS

QHP

Market Development

Medicaid/Medicare

Data Management

Quality Improvement

Conflict Resolution

Quality Assurance

Performance Improvement

EMR/EHR: EPIC & Athena

Knowledge of Facets and Member 360

Education

Ashford University – San Diego, CA4/2016

Master of Arts (MHA) – Organizational Management

Concentration: Healthcare Administration

Relevant Courses: Management Communications with Technology, Human Resources Management, Principles of Healthcare Administration, Strategic Planning & Marketing in Healthcare, the Functions of Modern Management, Legal Environment, Business Ethics

Tennessee State University – Nashville, TN6/2010

Bachelor of Arts (BA) – Interdisciplinary studies / Communications/ Business

Healthcare Experience

CHRISTUS Health – Irving, TX 4/2019- Present

Quality coordinator/ HEDIS Project Manager

Plan, develop, implement, and report outreach plans to build and maintain relationships and share information leadership.

Review and monitor members and providers submitted by provider; coordinate with directors, medical directors and CEO of the health plan.

Participate in coordinating and conducting annual site visits for quality review of provider clinical charts.

Establishes work priorities, and plans; directs and monitors project works.

Maintain Project issues and reports to health plan leadership and communicate to local steering teams on the progress of critical path items.

Identifies opportunities for clinical performance improvement and develops quality improvement initiatives related to clinical performance and other quality activities.

Responsible for concurrent and or retrospective review, data, abstractions, analysis, identification of critical issues, process improvement support, required education and assisting with measurement of performance metrics for different business units in the health plan.

Plan, execute, and evaluate complex program initiatives to improve Quality Performance for all Line of Business.

Manage and engage in interventions that improve CAHPS, HEDIS, and HOS for the highest level of quality clinical care and services

Coordinates and monitors the activates and results of surveys conducted for various purposes, including the CMS, required Consumer Assessment of Healthcare Provider and systems (CAHPS) and Qualified Health Plan (QHP) Survey.

UnitedHealthcare/OptumRx–Dallas,TX 1/2019-4/2019

Remote Clinical Quality Over reader (Contractor)

Performs Provider/Practitioner medical record reviews for HEDIS and HEDIS like measures as part of quality solutions Delivery.

Reviews assigned medical records.

Review verification of clinical data elements for HEDIS reporting.

Identifies findings supported by documentation guidelines with high level of accuracy.

Maintains HIPPA standards and confidentiality of protected health information; reports critical incidents.

Included collections and analysis coding and reimbursement guidelines.

Responsible for reviewing and researching medical records to determine the accuracy of coding, billing and supporting clinical documentation either in an health care facility.

Review results of laboratory test, verification of hypertension and the most recent blood pressure readings, colorectal cancer screening care, Immunizations, etc.

Managed competing timelines and prioritization of critical task.

Critical thinking skills to conduct research in a thoughtful and methodical search in order to locate specific claim information.

Participated in Web-Ex meetings pertaining to data integration/management, project & HEDIS initiatives.

Develop comprehensive, provider specific plans to increase their STAR performance.

Assisted with quality programs and provided analytics that leverage measures programmatically and meaningful for quality assurance.

Follow data management standards to ensure analytics and reporting meets, various quality initiatives needs while ensuring accuracy and quality of data.

Maintains current knowledge of requirements and guidance required in the performance of audit duties, including but not limited to ICD9 and ICD10, CMS.

UT Southwestern- Dallas, TX 6/2018- 9/2018

Quality Improvement/Medical Chart Auditor (Contractor)

Performed detailed process reviews and issued reports on risk and best practices and identified potential process improvement opportunities

Knowledge of business statistical analysis techniques and applications to measure the effectiveness, efficiency, productivity, and mission preparedness of established medical programs.

Coordinated/Facilitated reporting external audits conducted by project managers.

Assisted project managers on health systems within the organization.

Assisting with preparing documents and presentation material and reviewing project documents for accuracy and completeness.

Performed Coder Compliance auditing responsibilities for sections in the medical records department.

Chart analysis coding data auditing and validation; review medical records for the determination of accurate assignment of all documented diagnosis and procedures.

Providing Status reports to Project managers.

Knowledge of medical operations and management principles, policies, and procedures, and knowledge of medical plans, programs, and requirements.

Anthem, Inc. (Amerigroup) – Iselin, NJ 1/2018-5/2018

Contract Collector/ Quality Abstractor

Reviewed required data analysis and research within the Anthem data systems

Responsible for auditing CMS & or Commercial Insurance billing for diagnosis data collected from physician and hospital medical records.

Included collections and analysis coding and reimbursement guidelines.

Responsible for reviewing and researching medical records to determine the accuracy of coding, billing and supporting clinical documentation either in a health care facility or in Anthem assigned office.

Subject matter expertise in commercial insurance reimbursement/payment policies, audit reviews, analysis, and medical terminology.

Managed competing timelines and prioritization of critical task.

Critical thinking skills to conduct research in a thoughtful and methodical search in order to locate specific claim information.

Develop comprehensive, provider specific plans to increase their RAF/ STAR performance.

Assisted with quality programs and provided analytics that leverage measures programmatically and meaningful for quality assurance

Deep dive research based on Anthem specific platforms (i.e. Immunization registries, local claims system membership and defaulted claim information).

Index-entering information for electronic records in document imaging software

Follow data management standards to ensure analytics and reporting meets, various quality initiatives needs while ensuring accuracy and quality of data.

Maintains current knowledge of requirements and guidance required in the performance of audit duties, including but not limited to ICD9 and ICD10, CMS.

Reviews medical records that have been reviewed and coded by the coding vendor.

Measure Abstraction

Collaborating with doctors, coders, facility staff and a variety of internal and external personnel on a wide scope of Risk Adjustment & HEDIS education efforts.

Brident Dental & Orthodontics – Houston, TX 7/2014-9/2017

Patient Coordinator/ Lead Clinical Quality Specialist

Work collaboratively with clinical partners to ensure the quality and continuity of care.

Communicate effectively with a wide array of patients while promoting overall satisfaction.

Maintain accurate records and charts, monitor reports, and resolve various discrepancies.

Build relationships with patients, provide consultations, and communicate treatment details.

Verified and entered insurance information, including Medicaid, HMO, PPO and provided explanation of benefits EOB.

Assisted Clinical Quality Supervisors with training and implementations on various projects.

Abstracted, Overread and data entry of electronic medical and Dental records.

Developed communication work streams and training programs for clinical abstraction team.

Collaborated with vendors to ensure invoices were accurate.

Managing HEDIS Care Gaps, Scheduling patients for all preventive care.

Conducts physician chart audits (including research and presentation).

Monitored all major insurance contracts for Doctors to become in Network.

Medical and Dental abstraction of compliant and complete non-compliant records with expertise in HEDIS audits.

Constructing imaging software for project documents.

Assisted in maintenance of dental charts and or electronic dental records.

Coordinated HEDIS projects, supported the annual HEDIS project management by coordinating the identification, collection and abstractions of dental records and other data collaboration.

Target providers who would benefit from our Medical Risk Adjustment & HEDIS/STARS training

Establish and meet aggressive timelines for projects readiness completion.

45% travel to corporate office for mandatory meetings and training.

Provided leadership strategies mentoring, monitoring performance of clinical team.

Responsible for engaging, coaching and consulting with providers in regards to their continuous process improvement methodologies.

Liaison between providers, clinics, and collected supplemental data for HEDIS.

Created opportunities and participated in process improvements methodologies related to enhancing Humana, UHC, and health plan quality.

Planned, directed and coordinated large complex projects to ensure goals are met.

Lead projects to achieve key business objects.

Indexing-entering information for electronic records in document imaging software

Trained & Lead quality improvement activities that improve clinical quality & patient access to care.

Educate providers on how to improve their RAF scores and Stars ratings, which measures their patients’ health status.



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