Andre Burton, CPHQ, CRC
Liverpool,New York
Summary
Accomplished healthcare quality professional with a proven track record in driving quality outcomes and exhibiting strong leadership skills. Expert in analyzing and improving quality metrics and implementing effective improvement strategies. Successfully leads and guides quality coordination project teams, ensuring seamless collaboration and optimal results.
Overview
10
10
years of professional experience
1
1
Certification
Work History
Sr. Quality Practice Advisor
WellCare Health Plans, Inc.
East Syracuse, NY
05.2017 - Current
- HEDIS project leader for Upstate NY Syracuse region intake coordination staff
- Managed staff tasks from record retrieval to review and closing of chase
- Quality and risk adjustment program management in the Upstate NY region
- Advised and educated providers and IPA's across upstate NY region on appropriate HEDIS/QARR measures, risk adjustment documentation guidelines, and ICD-10/CPT coding use
- Coordinate with third party vendors and medical providers to facilitate on-site quality services and access for members
- Collaborated with provider relations, marketing, and other departments to improve provider performance and member experience in areas of quality, risk adjustment and operations
- Delivered and constructed specific reporting metrics to aide in educating providers on gap closing opportunities
- Reconciled quality and risk adjustment payments to allow for provider account posting
- Adjudicated medical claims through available software
- Top risk adjustment market performer
- Informed provider groups on CAHPS and HOS patient experience and health outcomes as it relates to quality, with the intent on improving scores for both
Risk Adjustment Provider Educator
Universal American
Liverpool, NY
12.2016 - 05.2017
- Educated providers and billing staff on risk adjustment practices and opportunities through the plans initiatives
- Managed RADV project for the upstate NY region from collection to review of chart
- Presented and discussed value-based care data to provider groups for quality improvement
- Informed medical practices on Medicare and Medicaid risk adjustment models
- Managed interdepartmental relationships with provider operations and contracting in efforts of improving provider satisfaction
- Administered clinical documentation improvement summits for providers in billing staff on risk adjustment principles
- Participated in special projects as needed
Respiratory Care Coordinator
Nunn's Home Medical Equipment
Syracuse, NY
12.2015 - 12.2016
- Processed patient intake documents and DME claims
- Reviewed clinical documentation for completeness, accuracy, improvement opportunities, and compliance with DME guidelines
- Assigned patients to diagnosis-related categories, using electronic medical records software
- Obtained medical authorizations based on medical necessity
- Communicated with providers and medical office staff to ensure continuity of care for referrals
- Educated patients on medical equipment use
- Coordinated delivery and set up of medical equipment
Account Quality Coordinator
Bates Troy Inc
Binghamton, NY
08.2014 - 08.2016
- On-site management of medical linen accounts within hospitals and long-term care facilities
- Implemented linen waste and cost reduction procedures and policies
- Responsible for over $200,000 in linen cost savings within a long-term care facility in upstate New York
- Educated clinical nursing staff on ways to utilize and prevent waste and abuse of medical linen
- Administered best practices of linen management and cost saving across the region
- Calculated required linen orders based on use expectancy data
Education
B.S. - Health Services Administration
Bryant & Stratton College
Liverpool, NYSkills
- HEDIS Metrics Expertise
- Medical Coding Expertise
- Risk Management Techniques
- Managed Healthcare Services
- Information Collection
- Performance Analytics
- Strategic Project Oversight
- Account Relationship Development
- ICD-10 Proficiency
- Understanding of HIPAA Regulations
- Document Analysis
- Operational Efficiency Enhancement
- NCQA Compliance Expertise
- Claims adjudication
- Expertise in Microsoft Office Suite
- Medical Terminology Proficiency
- Healthcare Documentation Analysis
- CAHPS
- HOS
- Lean Six Sigma Practices
Certification
- Certified Risk Adjustment Coder- 01519206
- Certified Professional in Healthcare Quality- 330656
Timeline
Sr. Quality Practice Advisor
WellCare Health Plans, Inc.
05.2017 - Current
Risk Adjustment Provider Educator
Universal American
12.2016 - 05.2017
Respiratory Care Coordinator
Nunn's Home Medical Equipment
12.2015 - 12.2016
Account Quality Coordinator
Bates Troy Inc
08.2014 - 08.2016
B.S. - Health Services Administration
Bryant & Stratton College