Medical Records Health Plan
Resume:
Miriam Fontanez
Quality Performance Measurement and Analysis
Lutz, FL., 33558
ad6z2s@r.postjobfree.com
EXPERIENCE
Independent Health, Remote NY — HEDIS Medical Record Reviewer
January 2024 - May 2024
(Temp) Review patient medical records to determine if the quality of care measures are met. Review data sources to determine any incentives or financial rewards for the health plan. Ensure accuracy and address any issues or errors that are found to discuss with the medical providers. Provide quality improvement consulting to improve any issues or errors. Review reports for accuracy of the HEDIS measure collected and get samples ready to be processed by NCQA auditors. Excels sheet of member demographic to research and investigate where to locate medical records, and HEDIS measures have been met within the data sheet. WellSense Health Plan, Remote NH, MASS — HEDIS
Medical Record Reviewer
December 2022 - December 2023
(Temp) Review patient medical records to determine if the quality of care measures are met. Review data sources to determine any incentives or financial rewards for the health plan. Ensure accuracy and address any issues or errors that are found to discuss with the medical providers or vendors. Review reports for accuracy of medical records collection from vendors. Review the claims data source to ensure medical records collection is accurate. Excels sheet of member demographic to research and investigate where to locate medical records, and HEDIS measures have been met within the data sheet. Create a pivot table and charts to present within a weekly meeting to summarize action that has taken place to resolve and meet daily goals.
Fontanez Innovative Consultant, Florida — HEDIS Quality Improvement Consultant
January 2020 - November 2022
(Contract) To work to improve the overall quality of medical or behavioral care that a hospital or other medical practice delivers to patients and families. Educate staff or providers on the correct standards for healthcare procedures which include proper documentation, coding, SKILLS
Analysis System Program:
Tableau, Oracle, SAS, SAP,
SQL, IBM Cognos Analytics,
Sigma.
EMR System: Athenahealth,
eClinicalWorks, Cerner,
Practice Fusion, Allscripts,
Kareo, EpicCare, Optum,
NextGen, Greenway, and
Office Practicum.
Software Programs: All
Microsoft products, EPIC,
Facets, Diamond, Quora,
Cotiviti, and Innovation.
Health Plan Subject Matter
Expert (SME): ICD 10 codes,
HCPCS codes, CPT codes, CPT
II & CPT III codes, HCC
coding, Medical record review
and documentation, Bright
futures, NCQA standards,
Prior Authorization, Appeals,
Appeals audits, Medical
records audits, Prior
authorization audits, Health
plan clinical guidelines, Data
collection, HEDIS, CMS,
Claims, Billing, Utilization
management, Case
management, Behavioral
health or Mental health
management, Medication
management, Regulatory
state contract, Medicaid,
Medicare, Commerical, and
all LOB's.
Miriam Fontanez
Quality Performance Measurement and Analysis
18205 Fall Creek Dr
Lutz, FL., 33558
ad6z2s@r.postjobfree.com
billing and reporting on quality of care. Excels sheet of member demographic to research and investigate where to locate medical records, and HEDIS measures have been met within the data sheet. Create a pivot table and charts to present within a weekly meeting to summarize action that has taken place to resolve and meet daily goals. Review excel sheets from the EMR system and investigate the performance levels and provide solutions or change action plans to provide a successful outcome. Magellan Health Plan, Remote AZ — Quality Improvement Specialist
January 2021 - October 2021
(Temp) Quality management principles and tools to improve processes, products, and services within the health plan. To maintain quality assurance and improve within the denial and approval processes for utilization management.
WellCare Health Plan, Florida — Quality Practice Advisor/ Quality Improvement Project Manager
May 2016 - November 2019
Project Manager roles: Serious Mental Illness (SMI) Population, manage HEDIS measures for this population and have quarterly quality improvement committee (QIC) meetings with contracted providers to manage these members or review, change and improve clinical guidelines. Other HEDIS measure projects to improve outcomes were asthma, diabetes, medication management and mental health management.
Practice Advisor roles: Educate staff or providers on the correct standards for healthcare procedures which include proper documentation, coding, billing and reporting on quality of care. Review patient medical records to determine if the quality of care measures are met. Provide quality improvement consulting to improve any issues or errors. EDUCATION
USF Corporate Training & Professional Education, Florida — Lean Six Sigma Green Belt Certification
December 2023
HEALTH CERTIFICATION
Basic Life Support (BLS) -
Certificate ID: 01HA643
Adults & Pediatrics First
Aid/CPR/AED -
Certificate ID: 01G7CVB
LANGUAGES
Fluent in Spanish
REFERENCES
Available upon request
Miriam Fontanez
Quality Performance Measurement and Analysis
18205 Fall Creek Dr
Lutz, FL., 33558
ad6z2s@r.postjobfree.com
USF Muma College of Business, Florida — Diversity, Equity
& Inclusion in the workplace Certification
May 2021
EBC Bushwick High School, New York City — High School Diploma
June 1997
PROJECTS
HEDIS Projects — NCQA Audits (January to May)
The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by more than 90 percent of the US health plans to measure performance on important dimensions of care and services. This project is a process to help identify performance gaps and establish a realistic target for improvement. This audit will look into information practices, control procedures, integrity of data, compliance with HEDIS specification, sampling methods, data collection, procedures, analytics file creation and reporting.
Measures Projects — Data Collection (June to December) Complete a statistical overview of HEDIS measures that need improvement. This project is to improve outcomes by identifying groups that have performance issues or errors within gaps of care.
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