Summary
Overview
Work History
Education
Certification
References
Timeline
Generic

Detries D. Posey

Baton Rouge,La

Summary

Over 20 years of providing support to Medical and Administrative Professionals Excellent time management/organizational skills. Managing multiple projects in fast-paced environments Managed HEDIS Projects Abstracted and audit ICD-9/10, CPT, HCPCS, HCC Coding codes from medical records for correct coding Trained in several EMR software, QSHR, LINKS, MACESS, QDAR, RX EFFECT, MEMBER 360, SHAREPOINT, XCELYS, TABLEAU, SAS, ORACLE, JOES PLACE, Windward, and other systems Batched medical records for billing Medicaid, Medicare and Commercial insurance, Credentialing, and Patient Collections Medicaid and Medicare claims review The primary function of the role is to develop organized analytics, reports and data management to support Quality Improvement within the Medicaid product line. Integrates data from multiple sources to produce requested or required data elements. Programs and maintains report forms and formats, information dashboards, data generators, canned reports and other end-user information portals or resources. The Senior Data and Reporting Professional influences Quality Improvement strategy. May create specifications for reports necessary for the quality management program. Makes decisions on moderately complex to complex opportunities which may support Member Engagement, Clinical Performance, Provider Engagement, Behavioral Health and Pharmacy. Exercises considerable latitude in determining objectives and approaches to assignments. Other responsibilities as determined by leader. Managed, counseled, and trained 20 plus employees. Disseminated and evaluated work of subordinates; setting daily activity schedules and monitoring time cards. Project Coordinator, Behavioral Health Coordinator, Contract Administrator, Arranged conferences/tele-conferences, meetings, and travel reservations. Maintained filing and record keeping systems. Exceptional skills in data entry and 10-key Prepared PowerPoint slides/presentations and proficient utilization of multiple databases, querying reports and producing excel spreadsheets. Dietary/ Housekeeping Manager Ordered, maintained and distributed supplies Knowledgeable of Medicaid insurance requirements for industry health plans to ensure compliance Liaison between members, providers and vendors; interacting and educating staff of HEDIS requirements experienced working knowledge of HEDIS program, measures and processes for Administrative and Hybrid projects to include HIPPA and NCQA regulatory guidelines. Work closely with upper management and leadership to give best practices Ensure quality numbers for the month is up to par Educating providers on best practices, Appointment Agendas, monitor monthly goals

Overview

12
12
years of professional experience
1998
1998
years of post-secondary education
1
1
Certification

Work History

HEDIS Reviewer III

Aetna CVS Caremark
12.2023 - 04.2025
  • HEDIS State Measure Abstracting
  • Reviewing Admin/Hybrid Data
  • Provider Scrub Cleanup
  • Scheduled on-site reviews with provider offices, medical groups, and other clinical facilities; travel to medical facilities around the state of Louisiana to complete chart reviews
  • Performed provider/practitioner medical record reviews, abstraction and data entry for HEDIS and HEDIS-like measures as part of the Quality Management and Performance program.
  • Reviewed medical records in order to abstract clinical data elements for HEDIS reporting, (results of laboratory tests, verification of hypertension and the most recent blood pressure reading, prenatal and postpartum care services, etc.)
  • Collected data from a variety of electronic and paper sources from provider offices and vendors (CIOX, MRO)
  • Maintain HIPAA standards and confidentiality of protected health information.
  • Communicate additional pursuit leads for additional medical records, if needed, to other members of the team.
  • Met daily abstraction and audit production goal.
  • Maintained quality requirement of 95% abstraction accuracy and timelines
  • 10 years of data reporting experience in healthcare.
  • Have experience working with HEDIS measures in Managed Care settings.
  • Advanced proficiency in SQL, SAS and other data systems
  • Develop and maintain reporting systems, analytical processes or other tools to support Quality and Clinical Performance, key benchmarks and improve Quality outcomes, i.e., HEDIS, NCQA, CAHPS, PIPS and state regulatory requirements.
  • Advanced Microsoft Excel skills including ability to link pivots to external data sources, creating pivot tables and summarizing data into reports and dashboards.
  • Strong analytic skills: Experience working with complex data sets within large organizations and/or the analysis of healthcare data including multi-level drill down assessment of key utilization and financial performance measures related to Population Health)
  • Proficiency in verbal and written communication to senior and executive leadership
  • Strong organizational skills and ability to manage multiple or competing priorities
  • Conduct onsite visits with provider groups in designated state.

Clinic Transformation Manager

United Healthcare
10.2022 - 10.2023
  • Deliver gap in care reports and work with provider offices to get members scheduled and gaps closed.
  • Provide education and support to provider offices.
  • Streamline/ simplify by providing direct communication between providers and Quality.
  • Providers will have direct access to speaking with experts with ability to explain details of performance measures, and their current performance rates, as well as provide resources to improve performance.
  • Abstract medical record year around, reduce copy vendor expense associated with HEDIS
  • Accountable for successful deployment of UHC’s Clinical Support program at the practice level, including but not limited to, introducing, and educating practices on the value/use of reporting tools, patient registries and delivery of reports via UHC’s Physician Portal
  • Accountable at a practice and market level, including but not limited to, educating practices about quality and utilization opportunities, program components and updates, and Case Management liaison.
  • Build and effectively maintain relationship with the practice leadership and key clinical influencers actively involved in practice transformation.
  • Support of clinical data and interoperability exchanges via available health information exchanges and market-wide platforms.
  • Regularly facilitate efficient, effective practice improvement meetings with the practice to monitor, present, and discuss progress on the transformation action plan and achievement in milestones.
  • Develop strategies; based on performance analysis, for improvement that includes specific outcomes and metrics to monitor progress to a goal and make recommendations for improvement.
  • Design practice transformation action plans and implement appropriate performance improvement initiatives designed to assist the practice in achieving contractually required transformation milestones.
  • Monitor and review the progress of the practice in milestone achievement and ensure the practice is accountable for successful completion.
  • Use data to analyze key cost, utilization and quality data and interpret results to assess the performance of the practice.
  • Use data to analyze trends and work with stakeholders to agree on and implement proactive strategies to address issues, and measure impact using a PDSA rapid cycle improvement approach, including external practice data.
  • Assist practices in creating workflows to optimize care delivery, introduce best practices improvements, and evaluate outcomes using rapid cycle improvements PDSA methods to reach mutual goals.
  • Educate & Deploy technology tools to support Practice Transformation.
  • Integrate technology tools into practice workflows.
  • Build and effectively maintain relationships with team members in the UHC Clinical organization as well Medical Directors, local Network leads, Health Care Economic Analysts and Clinical Analysts in support of the program.
  • Consult and partners with internal UHC matrix partners and the practice to identify organizational and structural challenges hindering achievement of desired program outcomes.
  • Collaborate with UnitedHealthcare teams including the practice Care Coordinators, quality management teams, hospital clinical teams, behavioral health teams to support integrated PCP driven care for our members with practices and hospitals.
  • Consult and guide the practice on developing innovative solutions, including bringing best practice experience and connecting practices with other high performing practices to spur innovation.
  • Work with the practice and Optum to align and integrate Optum care/disease management programs and population health services to augment the practice’s capabilities, support their care management efforts and add value to the patient care experience.
  • Assist and support department leaders in summarizing and disseminating experience – related learning's by way of team updates, written reports/articles, and/or presentations as called for by directors.

Provider Practice Coordinator

WellCare of Louisiana
06.2018 - 10.2022
  • Project Planning HEDIS
  • Provider Quality Presentation
  • Gap Closures (HEDIS MEDICARE)
  • Med Adherence
  • Quality Provider Scorecards/Member Detail Reports
  • Provider/member facing
  • Conduct Health fairs through several regions in LA
  • Vendor Support
  • Provider/member/pharmacy outreach
  • Appointment Agendas
  • HEDIS TOOLKITS/HEDIS CODING/CPT II Coding
  • PIP
  • Work closely with upper management and leadership to give best practices
  • Ensure quality numbers for the month is up to par
  • Educating providers on best practices, Appointment Agendas, monitor monthly goals
  • Build relationships with the providers and members

HEDIS Facilitator

Healthy Blue of LA
11.2017 - 06.2018
  • Company Overview: through Aerotak Staffing
  • Process incoming/outgoing mail
  • Scheduled on-site reviews with provider offices, medical groups, and other clinical facilities; travel to medical facilities around the state of Louisiana to complete chart reviews
  • Performed provider/practitioner medical record reviews, abstraction and data entry for HEDIS and HEDIS-like measures as part of the Quality Management and Performance program.
  • Reviewed medical records in order to abstract clinical data elements for HEDIS reporting, (results of laboratory tests, verification of hypertension and the most recent blood pressure reading, prenatal and postpartum care services, etc.)
  • Collected data from a variety of electronic and paper sources from provider offices and vendors (CIOX, MRO)
  • Maintain HIPAA standards and confidentiality of protected health information.
  • Communicate additional pursuit leads for additional medical records, if needed, to other members of the team.
  • Met daily abstraction and audit production goal.
  • Maintained quality requirement of 95% abstraction accuracy and timelines
  • Provider scrub listing
  • Performed medical records data entry
  • Through Aerotak Staffing

Intake Coordinator/Reimbursement Specialist

Carepoint
10.2016 - 06.2017
  • Company Overview: through Select Staffing
  • Retrieve Auth
  • Work Held Revenue
  • Work Retro Auth
  • Re-auth Report
  • On tracking Report
  • Obtain Clinicals for all Bayou Health Plans
  • Assist with Credentialing
  • Audit ICD 9/ICD 10/HCPS/CPT CODES HCC Coding for billing
  • Corresponding emails
  • Contact Patient and Physicians
  • Work Denials and Appeals
  • Assist employees with daily duties
  • Retrieve Payments
  • Through Select Staffing

HEDIS Quality Abstractor/Coordinator

Amerigroup
11.2015 - 06.2016
  • Company Overview: through Populus Group
  • Performed medical record over reads
  • HEDIS chart abstraction
  • Onsite medical records review
  • Onsite chart retrievals
  • Abstracted ICD-10, CPT, HCPCS codes from medical records
  • Chase chart
  • Assist with BH assessments
  • Request Medical Records for ADMIN/HYBRID
  • Understand NCQA/ State HEDIS Measures
  • Train employees
  • Passed ALL Medicaid NCQA/STATE measure testing
  • Audit ICD 9/ICD 10/HCPS/CPT CODES for billing
  • Through Populus Group

Billing Coordinator

Moreau Physical Therapy
07.2015 - 11.2015
  • Company Overview: through Comed- West staff
  • DME Billing
  • Setup Credentialing Paperwork
  • Audit CPT, HCPCS, ICD 9/10 codes HCC coding for billing
  • Correction of codes and modifiers
  • Over read and process all claims
  • Post payments
  • Review Medicaid and Medicare guidelines and fee schedule
  • Work Hold Report
  • Work Denials
  • Send out patient statements
  • Collect payments from Insurance and Patients
  • Through Comed- West staff

HEDIS Coordinator

Louisiana Health Care Connections
04.2015 - 07.2015
  • Company Overview: through Healthcare Support
  • Abstracted medical records for all HEDIS Measures
  • Performed medical records overreads on all hybrid measures for client accuracy
  • Research provider billing in CRM for Supplemental data request
  • Enter compliant records in QSHR- hybrid
  • Audit ICD 9/ICD 10/HCPS/CPT CODES HCC Coding for billing
  • Assist with BH members
  • Enter all compliant records in SDS IU
  • Report and track issues and outcomes related to abstractions to HEDIS Coordinator
  • Input data in SharePoint, fax, mail and request supplemental data from providers
  • Onsite chart reviews and abstraction
  • Through Healthcare Support

HEDIS Project Coordinator

United Healthcare Group
01.2015 - 05.2015
  • Company Overview: through Randstad Staffing
  • Abstracted ALL hybrid Measures from medical records
  • Member and Provider BH outreach
  • Requested and Collected charts by fax or mail
  • Batched chases for vendors overview
  • Entered complaint and non-compliant records in system
  • Verify each member chase report
  • Coordinates and performs onsite medical record reviews
  • Audit ICD 9/ICD 10/HCPS/CPT CODES HCC Coding for billing
  • Educates providers and office staff on proper coding and billing practices
  • Train on HEDIS and state-mandated quality metrics specifications
  • Created invoices for pay for performance measurement, and State Measures
  • Coordinate Behavioral Health assessments
  • Trend and Track all provider and member barriers
  • Supported to HEDIS Nurses
  • Participated in and representing the plan at community events , departmental, and other organizational meetings focusing on quality improvement, member education, and disparity programs
  • Received Award/ Plaque meeting the AWC State Measure
  • Through Randstad Staffing

Account Advisor

Blue Cross Blue Shield LA
10.2013 - 10.2014
  • Educated providers and members regarding claims issues
  • Processed medical claims
  • Audit CPT-4, ICD-9 and HCPCS codes from claim forms and input findings in claims system for adjudication
  • Maintain a quality score of 97% or higher for claims abstraction
  • Reviewed medical records and claims for proper payments
  • Educated members on benefits
  • Work in T point to resolve claims issues
  • Updated systems with claims status

Education

Capitol Sr. High School
Baton Rouge, La

Certification

CHQT HEDIS Certified

References

  • Paula Thompson, Director of Quality, 225-278-6629
  • Lesley Mattews, HEDIS Manager, 225-301-7720
  • Michelle Root, UHG CQI Manager, 712-314-4823

Timeline

HEDIS Reviewer III

Aetna CVS Caremark
12.2023 - 04.2025

Clinic Transformation Manager

United Healthcare
10.2022 - 10.2023

Provider Practice Coordinator

WellCare of Louisiana
06.2018 - 10.2022

HEDIS Facilitator

Healthy Blue of LA
11.2017 - 06.2018

Intake Coordinator/Reimbursement Specialist

Carepoint
10.2016 - 06.2017

HEDIS Quality Abstractor/Coordinator

Amerigroup
11.2015 - 06.2016

Billing Coordinator

Moreau Physical Therapy
07.2015 - 11.2015

HEDIS Coordinator

Louisiana Health Care Connections
04.2015 - 07.2015

HEDIS Project Coordinator

United Healthcare Group
01.2015 - 05.2015

Account Advisor

Blue Cross Blue Shield LA
10.2013 - 10.2014

Capitol Sr. High School
Detries D. Posey
Want your own profile? Build for free at Resume-Now.com