Health Data
Resume:
PERSONAL INFORMATION
Citizenship: United States of America
Veterans Preference: N/A
Highest Federal Grade Held: N/A
Desired Location: MD, DC, VA-Northern
Availability of Job Type: Permanent
Work Schedule: Full Time
Contact Supervisor: Yes
SUMMARY OF QUALIFICATIONS
Highly qualified and experienced Healthcare Analyst and Program Administrator professional with 10 years of experience in Healthcare Policy, Medicaid-CHIP program, Eligibility, MMIS, Customer satisfaction, program management, Pre- and Post-award, and administration while demonstrating solid analytic, Medicaid program/Audits, and problem solving skills. Expertise in program monitoring, contracts management, finance/ budgetary maintenance, communication, and program evaluation.
WORK EXPERIENCE
NCI, Information Systems
Centers for Medicare & Medicaid Services (CMS) Contractor
11730 Plaza America Dr. Reston, VA 20190
Supervisor-Melissa Rinehart
Data Processing Subject Matter Expert (Project Manager III)
11/2018-Present
Provide technical direction and guidance to the data processing team and to the CMS stakeholders.
Provide expertise and general claims support to teams in reviewing, researching, and investigating claims processing systems and processes.
Create training material based on CMS guidelines and federal regulation requirements.
Create and update standard operating procedure guidelines for team.
Monitor data processing workflow to ensure timely and accurate findings.
Assist team with performing quality assurance reviews of completed audits.
Conducts queries, and communicates data findings in written and oral reports, as well as presentations.
Analyze data to determine appropriate actions for completing reviews timely.
Responsible for determining any knowledge gaps, work process improvements, and technical system updates to assist with creating streamlined audit process.
Assist with creating review schedule to ensure milestones are met on time.
A+ Government Solutions, LLC. /CNI Advantage LLC, Rockville, MD
Centers for Medicare & Medicaid Services (CMS) Contractor
1300 Piccard Drive Suite 204
Supervisor-Janice Murray 301-***-****
Okay to contact Supervisor
Rockville, MD 20850
Health Insurance Payments Manager
Promotion
40 Hours/Week
08/2018-11/2018
Program Operations
Manage a team of 31 Health Insurance Payments Analyst that are responsible for conducting audits to determine if reimbursements to medical providers are in compliance with regulations and policies.
Responsible for evaluating new hires at 30/60/90 day mark.
Responsible for disciplining and coaching new hires and existing employees.
Analyzes federal CFR and state regulations /policies for Medicaid and CHIP reimbursements.
Interacts with Medicaid state personnel to schedule audits and explain audit findings.
Assist team with performing quality assurance reviews of completed audits
Conducts queries, and communicates data findings in written and oral reports, as well as presentations.
Analyze data to determine appropriate actions for completing reviews timely.
Responsible for determining any knowledge gaps, work process improvements, and technical system updates to assist with creating streamlined audit process.
Oral/Written Communication
Independently conduct state orientation data and system intake meeting.
Participates in internal and external management meeting that requires subject matter expertise and recommendations.
Responsible for creating reports to share with CMS stakeholders and state personnel.
Rockville, MD 20850
Data Processing Assistant Manager
Promotion
40 Hours/Week
04/2018-Present
Program Operations
Responsible for serving as the subject matter expert for the Data Processing (DP) review team.
Collaborates with DP state leads and state personnel to determine readiness for the initiation of DP reviews.
Supervise a team of 31 employees which include, daily monitoring of productivity, Employee evaluation, timesheet approval, reviewing/approving leave request.
Monitor and Control DP Team by monitoring the outputs of team final product.
Conduct audits as business needs dictates by traveling onsite or completing review remotely.
Oral/Written Communication
Independently conduct state orientation data and system intake meeting.
Participates in internal and external management meeting that requires subject matter expertise and recommendations.
Responsible for creating reports to share with stakeholders.
System Analysis
Assist with development of review workflow processes and identifies system enhancements
Participates in Joint Application Design (JAD) Sessions
Data Analysis
Assist in the development of continuous improvement by analyzing the Sample Unit Coordination (SUD) data that identifies gaps, and areas for improvement.
Rockville, MD 20850
Senior Health Insurance Payment Analyst III (Team Lead)
Promotion
40 Hours/Week
06/2016-04/2018
08/2015-06/2016
Health Insurance Payment Analyst I
40 Hours/Week
Program Operations
Conduct detailed and precise audits of claims processing systems (MMIS) across the United States onsite and remotely to determine if states paid Fee-for-Service and Managed Care claims according to Medicaid Federal Code of Regulations (CFR) and state regulations under the Payment Error Rate Measurement Project (PERM).
Responsible for conducting audits of Inpatient claims, Behavioral Health, Home Health, Nursing Home, ICF/MR, Pharmacy, Outpatient, school based/day Habilitation/Waivers, Personal Care, Fixed payment (HIPP Payment), Medicare Crossover, Non-Emergency Medical Transportation, Clinic (FQHC, and Rural Health), Dental claims and Managed care capitation payments.
Researched, Analyzed, interpret and applied provider Medicaid enrollment, recipient eligibility (CHIP and Medicaid), risk based screening, and claims processing, CFR and state regulations when conducting audits of state claims.
Responsible for adhering to patient confidentially by following HIPPA Regulations.
Supervised data processing review personnel and monitor work flow to assure quality and timeliness of deliverables.
Responsible for approving timesheets for employees by verifying hours worked and approved leave time entries.
Managed a team 12-24 reviewers to ensure completion of assigned work, respond to review questions, and create operating procedures for navigating state MMIS systems.
Assigned work to reviewers and manage workflow through State Medicaid Error Rate Findings (SMERF) system.
Professional Systems
Simultaneously use the State Medicaid Error Rate Findings (SMERF) web-based system, State MMIS and eligibility systems to accurately conduct audits.
Knowledge of various State Medicaid Management Information System (MMIS) and Eligibility Systems.
Oral/Written Communication
Conduct state orientation calls to gather information regarding state procedures using standardized state questionnaire, discuss site visit dates, and review PERM process and expectations.
Responsible for communicating with the client, Centers for Medicare and Medicaid (CMS), any impediments that impede the team’s ability to complete audits accurately and on time.
Responsible for communicating with state liaison (onsite or remote) throughout the PERM cycle.
Draft desk aids for data processing reviewers based on state policies and system manuals.
Conduct exit conference with state liaison and staff members to update state of completion status of reviews, discuss pending issues identified by level 1 reviewers, and determine future visits if needed.
Quality Assurance
Independently conduct inter-rater reliability (IRR) at 10% random sample to ensure accurate and concise audits of level one reviewers.
Responsible for completing 100% level 2 reviews that ensures all cited errors are cited using the correct qualifiers and over-turn incorrectly cited errors.
Individually reviewed over 1500 claims in a cycle and of those cited 377 errors that were upheld by senior reviewer.
Applied company guidelines that are used to assist with the collection of accurate and symmetrical data when completing audit reviews.
Administrative Support/Problem Solving
Support management with training new employees on using SMERF system and how to navigate state systems.
Used Critical thinking skills to determine under and over payments when auditing claims by consultation with state lead or request explanations in writing for such payment.
IT/System Testing
Coordinated with IT to create system requirement specification for SMERF system updates
Tested updates to SMERF system to determine functionality needs
Department of Health and Mental Hygiene, Baltimore, MD
201 West Preston Street
Baltimore, MD 21201
11/2014-08/2015
Agency Grant Specialist II
Office of Preparedness and Response
Supervisor- Christopher Snyder, 410-***-****
Okay to contact this supervisor
Program Operations Management/Monitoring
Monitored the life cycle of all grants (Pre-and Post-award), budget and expenditures for the Department of Health and Mental Hygiene (DHMH) Office of Preparedness and Response (OPR) cooperative agreements for the Department of Health and Human Services, Center for Disease Control and (CDC) and Prevention and Assistant Secretary for financial Resources (ASPR)
Provided administrative support by providing grants management services, managing procurement, preparing budget reports and maintain accurate records.
Supported senior management in maintain fiscal records of preparedness activities that include syndromic surveillance, plan implementation, incident reports and after action reports when responding to an emergency activation.
Performed reconciliations and audits of grant expenditures by sub awardees, vendors and OPR expenses.
Grants Management
Successfully retrieved Funding Opportunity Announcement (FOA) through the Grants.Gov portal to review grant opportunity specifications in order to complete budget narrative and/or budget justification for Grant Application submission.
Responsible for designed, developed, implemented and interpreted grants/ assistance management policies, procedures, and using best practices when monitoring cooperative agreements for CDC and ASPR.
Provided training and technical assistance to senior staff as requested.
Maintained complex tracking for procurement expenses for existing and new equipment.
Developed and implemented complex tracking system for all federal awards awarded to the department using the grants Catalog of Federal Domestic Assistance (CFDA) number.
Provided assistance to senior fiscal officer in completing Federal Financial Reports throughout fiscal year and year-end closeouts.
Key Accomplishments
Designed complex tracking system to track and prevent lapse of funds and cost overruns by developing pivot tables in excel to track each object code and description of expenses.
Financial Management/Financial Analysis
Monitored a budget over $30 million that include carryover funding from previous fiscal years.
Responsible for accounts payable paid by invoices used pay blocks according to the state of Maryland General Accounting principles.
Successfully drew down expenses by the required due date set forth by the Notice of Award (NOA).
Provided support in completing quarterly projections by data entry using the complex tracking system to appropriately project expenses for each quarter.
Supported senior fiscal officer in conducting cost/price analyses of grants by reviewing projected projects and researching cost based on historical data or by requesting quotes from vendors.
Administrative Support/Problem Solving
Independently reviewed and approved employee expense reports by calculating expenses and comparing to allowable cost documents set forth by General Accounting.
Independently balanced payroll by re-allocating funds between grants by data entering and creating journal adjustments.
Assisted senior fiscal officer with arrangements and payments of employee travel.
Written & Oral Communication
Drafted budget narrative used to assist with the completion of budget requests.
Developed correspondence, and standard operating procedures that adhere to CFR and COMAR regulations.
Developed information packages for employees and awardees. As a result, a combination of informational material and instructive material developed.
Served as liaison and Participate and represent senior fiscal officer at staff meetings and conferences.
Department of Health and Mental Hygiene, Baltimore, MD
201 West Preston Street
Baltimore, MD 21201
7/2008-12/2014
Medical Care Program Specialist II
Non-Emergency Medical Assistance (Medicaid) Transportation Grant
Supervisor- John Pelton, 410-***-****
Okay to contact this supervisor
Program Operations Management/Evaluation
Monitored 23 counties and 1 independent city in the state of Maryland, Medicaid Transportation Grant program to adhere to budget requirements and to ensure grantees, and providers follow program goals and objectives, regulations in accordance with Federal Code of Regulations (CFR) and Maryland State Code of Maryland Regulations (COMAR)
Analyzed and evaluated Program for efficiency and effectiveness of health care delivery and health initiatives by participating in routine audits (onsite reviews) of each jurisdiction ensuring compliance with COMAR regulations, Medicare and Medicaid regulations and Maryland State Transmittals.
Oversaw program integrity by randomly selecting 4,000+ recipients and performing Motor Vehicle verifications, screen contractors and sub-contractors for excluded individuals and entities using the list of exclusions identified on the Health and Human Services OIG portal, SAM.gov portal, and DHMH site pages.
Performed investigative and highly sensitive annual onsite reviews to ensure compliance with COMAR regulations, CFR regulations, Program guidelines and Maryland State Transmittals by reviewing previous onsite reviews, financial statements and receipts, and expenditure reports.
Provided oversight of program integrity to ensure contractors and sub-contractors of each jurisdiction provide services that are outlined within the scope of their contract.
Independently screened and assisted recipients by directing to the appropriate service in order to access their healthcare needs.
Policies/Regulations/Data Collection/Research
Interpreted and applied COMAR regulations, guidelines, and polices of the Medicaid Transportation Program, Medicaid recipient eligibility, provider enrollment, and Medicaid Managed Care.
Analyzed data for recipient Medicaid transportation needs by researching, formulating, and recommending the development of additional and/or modify policies and procedures to improve the efficiency and effectiveness of the Medicaid Transportation Grant program.
Conducted extensive research of other transportation programs in the United States by using the internet and conducting interviews via telephone. Research projects were used to collect data to compare and contrast best practices to develop and adopt to the state of Maryland Medicaid Transportation program.
Supported senior analyst in providing leadership and Medical Assistance Transportation guidance to state legislatures during conferences and workshops. Lead the consumer satisfaction survey focus working group to develop new strategies for coding, collection of data, and interpreting findings and assist, participate and represent state agency in appeal hearing, meetings, and, conferences.
Evaluated and provided guidance on Managed care or Medicaid fee-for-service appeals.
Key Accomplishments:
Successfully collaborated with staff in drafting program policy and procedures Transportation Guide Manual and Conditions of Award. Creation of these documents enabled grantees to be in compliance with rules and regulations that were set forth by COMAR and the CFR. Compliance increased by 10% since the onset of the revised documents.
Training
Conducted training, and represented upper management at meetings and training seminars.
Key Accomplishments:
Managed, developed, implemented, and evaluated training curricula on Medicaid Managed Care, and Medicaid Transportation program that is used to instruct providers, grantees, and health professionals on program policies and procedures that resulted in 10 training dates per year and a 95% training satisfaction rate.
Program Budget
Monitored multiple budgets for a total of $43 million of grant funds for the Maryland Medicaid Transportation Grant Program to ensure accuracy and adequacy by using Microsoft excel to track and monitor all phases of awards to prevent lapse of funds or cost overruns, independently review quarterly expenditure reports to ensure compliance with fiscal and administrative policies, process and review supplement, modification and reduction request.
Effectively reviewed initial budget request by evaluating program narrative and data worksheet for completeness, review of appropriate justifications for requested expenses.
Data entered and tracked quarterly expenditures for each county by keying in excel database. This document is sent the fiscal administrator and division chief for review.
Key Accomplishments:
Successfully prevented cost over runs by developing quarterly expenditure report. This report listed all line items that are allowable to the program, what the program is allotted and what they have actually spent for that particular quarter. This report is used to monitor and prevent fraud, waste and abuse of federal and state funding. In reviewing these documents I have identified over 20 inappropriate expenses and 3 reports over their allotment.
Successfully developed Non-Emergency Transportation Program (NEMT) Allowable cost document that served as guidance to grantees ensuring appropriate expenses for each program. As a result of this document, I have been able to successfully review each county program budget against this document to ensure compliance. Identified over 20 inappropriate expenses and three reports over allotment
Oral and Written Communication
Developed correspondence, and standard operating procedures in drafting COMAR regulations to improve compliance with state and federal Medicaid and Medicare regulations, and provide technical guidance by collaborating in the development of the Medicaid Transportation Program integrity manual.
Developed presentation material and information packages for recipients, providers and grantees. As a result, a combination of informational material and instructive material developed.
Participated and drafted meeting minutes that advised work efforts and resolves problems within the Transportation Grant Program.
Coordinated community outreach activities with outside sources i.e. Kennedy Krieger Institute, Nursing homes, local hospitals, Dialysis centers where presentation of complex and sensitive information regarding Medicaid are discussed.
Key Accomplishments:
Designed program webpage using SharePoint www.dhmh.state.md.us/mma/communitysupport/ambulance and developed new audit reporting system and procedure to assess the efficiency and effectiveness of the Medicaid Transportation program.
Provided consultation and collaboration, and serve as a liaison to over 10,000 potential Medicaid Transportation recipients and 24 grant managers that include identifying and analyzing issues, resolving problems, and challenges facing the Medicaid Transportation program through investigation, research and surveys where resolutions are provided to management for consideration.
Consulted with recipients to assist with making referrals for alternative transportation programs that fit their needs.
EDUCATION
Towson University, Towson, MD US
Degree: Master of Science Health Science
Credits Earned: 27 Credit hours
Major: Community Health Concentration
Relevant Coursework: Health Care Systems, Introduction to Health Behavior, Introduction to Public Health, Health Administration, Program Planning, Community Health: Qualitative & Quantitative Analysis, Program Evaluation, Research Methods
Towson University, Towson, MD US
Degree: Bachelor of Science Health Science, 12/2007
Credits Earned: 128 Credit hours
Major: Community Health
Related Coursework: Technical Writing, Information and Technology for Business, Chronic & Communicable Disease, Epidemiology Basis of Disease & Environmental Health, Measurement & Evaluation in Health Education, Organize, Implementation & Program Management
Training Courses
Technical Institute of America-Project Management Certification Training Course Certificate of Completion 05/2018
REFERENCES
Furnished Upon Request
Contact this candidate