Human Resources Quality Improvement

Shannon M. Gilbert

Hemet, California

Cell: 213-***-****

***********@*****.***

Versatile, purpose-driven leader with 25+ years of comprehensive experience providing Quality Improvement, Regulatory Compliance, Human Resources, and Data Validation Management. Educated, developed, and implemented improved managerial processes to create an environment that guides employees to accomplish department and individual goals. Recognized for collaborative leadership, while unlocking employee’s potential through motivation, encouragement, and accountability. Proven track record to drive maximum organizational efficiency, and interdepartmental participation.

Key competencies:

Medical terminology and usage of strict techniques resolving national level risk adjustments, EOB’s, Denial recovery, ICD-10 coding inconsistencies, E&M, CPT, and HCPCS Level II codes for reimbursement purposes. Top performance reviewer for workman’s compensation claims, Chargemaster creation, Milliman care guidelines (MCG), HCC data validation, National Language Processing (NLP), Initial Validation Auditing (IVA) and HEDIS monitoring. Vast knowledge in reviewing Key performance indicators (KPI’s) and Corrective action plans (CAPS) to execute quality improvement measures. Senior expert in abstracting, posting, adjusting, collecting, and utilization of the NCCI editing/auditing tool sets. Expert level processing smart sheets, standard/expedited grievances and appeals, UB-04 HCFA1500 claims forms for all healthcare payers, various specialties, and levels of care. Advanced understanding of the utilization/referral and case management process. Sound knowledge of provider relations and client services. Concise understanding of the NCQA standards and CAQH credentialing accreditation process. Key knowledge of generally accepted accounting principles and financial audit principles. Solid understanding of DMHC, DHCS, CMS, and PACE data monitoring and reporting. Strong analytical and problem-solving skills. Excellent oral and written communication skills.

Key Technology and Methodologies:

70 WPM, 10 key, Microsoft Teams, Word, Excel, Access, Power point, Codify, Turbocoder, EncoderPro, WinZip, Sharepoint and Outlook systems, SalesForce, KIPU, Cerner, Epic, Artiva, Vitalware, WebAba, DSG, SSI, DDE, MDX, PBAR, EZ-Cap, IDM, ZirMed, OSCAR, HST, Crystal reports, IMAX, MedAvant, PIP, Emdeon, OptumMCG, Onbase, Powerchart, Chartfinder, Rightfax, Laserfiche, All EHR EMR systems, NextGen, EZ-Care, Nthrive, IDX, Star HBOC, Healthland Infinity, Athena Athena POP, Allscripts, A/S 400 MedFM, RCI, Medi-Tech, PowerBI, Smartsheets, Invision, MMOTS, RADDB, HPMS, CDAT portal usage. MAS90 Accounting systems and multi facet payroll system.

Experience:

UCLA Health

March 2018-Present

Employee Relations Administrator (P/T Remote)

Key support to the Vice President of Human Resources. Manages staff recruiting, executive leadership and legal teams. Serves as liaison between Human Resource and administration staff to manage all aspects of employee relations investigations. Track and review disciplinary procedures, including performance improvement plans. Serves as a subject matter expert to interpret, support and guide internal and external employees on compliance and employee relations policies. Educate and implement provisions, policies and new processes to leadership, staff and stakeholders. Direct and maintain high-level tasks like scheduling, communication, project management and reporting.

Choice Medical Group

April 2024-Present

Quality Improvement RAC Manager

Manages Medicare 5Star, Commercial, Global Quality P4P, and Risk Adjustment Coding staff who have the responsibility for the implementation of HEDIS and Risk activities, including the identification, collection and abstraction of medical records and other data in support of annual HEDIS project management and ongoing review of medical records submitted by providers. Travels to physician practices and regional offices. Participates in new employee selection processes and conducts new hire training for internal staff. In charge of full cycle payroll for staff. Spearheads the programs’ execution with appropriate tactics and reporting requirements in place. Participates in meetings with the Health Plans, vendors and HEDIS auditors. Provides data collection and report development support for Quality Improvement programs and performance improvement projects. Identifies and oversees new supplemental data sources for use in HEDIS reporting. Managed a staff of ten employees.

Welbe Health PACE

June 2022-December 2023

Quality Improvement (Remote)

Collaborated with the Medical Director on reportable incidents including, but not limited to, unexpected deaths, elder abuse, infectious disease outbreaks, falls with injury and/or serious traumatic injuries while completing root cause analysis on reportable events. Collected, analyzed, and generated data for departments requiring corrections issued by the state and federal agencies. Filed and tracked near miss and reportable incidents using smart sheets. Managed submissions to regulatory agencies included but not limited to HPMS quality reporting and enforced corrective action plans. Led the staff through the preparation for the successful completion of all state and federal audits. Reviewed participate grievances and tracked complaints. Drafted and performed final edits of participate grievance letters. Led and completed the meeting minutes for all QI Program Committees, including but not limited to the Professional Medical Advisory Committee, Quality Improvement Committee, Participant Advisory Committee and Patient Safety & Ethics Committee. Responsible for building relationships with state and federal regulatory agencies, including the Centers for Medicare and Medicaid Services and Medicaid Fraud Control Units. Facilitated daily interdisciplinary care team (IDT) meetings. Investigated and resolved medication related errors, while working with the clinic and pharmacy to initiate quality improvement measures.

Centered Health

September 2021-June 2022

Admissions Counselor (Remote)

Set record goal of monthly target for admissions. Met over 100% of quarter benchmark and ranked highest in admission totals. Monitored viable leads by utilizing marketing tracking software. Qualified individuals into various Mental Health, Detox and Eating Disorder programs for residential, PHP and IOP services. Administered Mental Health pre-assessment applications to coordinate best treatment options for clients. Dictated, uploaded, and validated clinical documentation for admittance. Initiated and negotiated single case agreements with out of network insurance companies. Requested modification and extensions of authorizations for utilization management. Documented and retrieved new client’s medical conditions, past treatment, and medications list. Scheduled new admits and coordinated with the clinical team on important barriers and client's accommodations. Marketed programs and facilities by preparing and providing informational brochures, answering questions, and conducting tours of the clinic. Conducted census review to ensure out of pocket expenses were collected. Audited all files and complied with organization standard for admit protocol. Generated discharge reports to arrange after care and care coordination for clients. Streamlined new processes on how to improve workflow and recommended new marketing strategies.

College Medical Center.

January 2020-September 2021

Commercial Account Manager

Managed high dollar encounters for all payers by performing one touch resolution. Recovered over 1.3 million unpaid claim payments from various insurance companies and hospice facilities. Scrubbed, updated, modified, and cloned UB-04 billing claims for initial and re-bill submission when needed. Examined approved authorization to validate TOB, units and charges were billed correctly for PHP and IOP services. Coordinated with case management for timely admission processing. Requested retrospective authorizations and monitored rightfax infrastructure modifications that were needed. Reconciled all credit balances, offsets, and refund requests. Identified trends, claim payment discrepancies, and reported errors to the proper department for correction. Submitted first and second level technical appeals. Prepared clinical documentation and uploaded bundle in patient records. Generated various census reports to prioritize weekly goals. Reached 100% of target bonus for my department, performance, attendance, and productivity goal. Managed a staff of five employees.

Centers for Medicare & Medicaid Systems

Covina, CA September 2014-December 2020

Senior Internal Auditor (Part-Time)

Organized documents according to the system hierarchy and presented a professional package to providers of service and on-site operators. Targeted and educated providers on the Unified Program Integrity Contractor audits, Supplemental Medical Review Contractor audits and supplied comprehensive error rate testing tools for audits. Performed coding inconsistencies utilizing CMS audit tools. Coached providers on tips for a successful audit. Applied risk and control concepts to guide auditees to proper resolutions. Prepared flowcharts and narrative reports for divisions of service. Write/revised corrective action plans based on the control descriptions provided by lead surveyor. Ensured performance indicators results were well-documented based on a complete and accurate understanding of the audit results.

Optum United Health Group

July 2012-August 2017

Senior Project Manager (Remote)

Collected and abstracted relevant data needed to perform and complete RADV and National audits. Negotiated between Health Plan and copy service to facilitate charges, budget and rejected charts. Generated formatted reports to support critical quality improvement functions. Monitored and reported key performance measurement activities required by Centers for Medicare and Medicaid services. Validated all data for risk adjustment and HEDIS audits. Developed detailed project plans and met deadlines. Proactively monitored the right fax system capacity while applying modifications as needed. Worked between several data platforms simultaneously, to complete mock review. Submitted final audit bundles through required data release protocols (CDAT). Investigated, detected, and reported breaches and up coding. Reviewed, investigated and resolved grievances, appeals and second level appeals. Managed a staff of seven employees.

Education:

San Pedro High School Diploma 1999

Training Certificates:

First Aid/CPR and AED

Fire and Life Education & Safety

Training Diploma:

AAPC Certified Outpatient Coder HCC/CRC Risk Adjustment Coder

Volunteering:

South Coast Botanical Garden- SOAR program 2021-Present

Youth Moving On-At risk youth counselor 2018-Present

Didi Hirsch Mental Services-Suicide Prevention program 2016-Present

JWCH Institute-Community outreach counselor 2016-Present

Key achievements:

Managed a staff of 10 members.

Conducted root-cause analysis while troubleshooting network and system problems.

Performance history of success implementing multi-faceted systems; new system implementation.

Streamlined processes to monitor days in receivables and trends of denial resolve rate queue.

Trained and mentored staff on stress management and conflict resolution.

Conducted on-going sensitivity training for both clinical and non-clinical staff.

Leading people and quality improvement team’s summit. (Yearly attendee)

Awards:

Team collaboration and performance for the RADV & NAT15 CMS project.

Performance excellence for the RADV Government ACA and HEDIS audit project.

https://www.linkedin.com/in/shannon-gilbert-

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