Eleanor Hou
Clinical Documentation Specialist
Naples,FL
Summary
Experienced Clinical HEDIS Documentation Specialist with a proven track record in providing strategic insights and effective solutions to clients. Skilled in leading projects to improve operational efficiency and drive business growth. Strong problem-solving abilities and adept at managing client relationships to ensure successful outcomes for all stakeholders.
Overview
13
13
years of professional experience
1
1
Certification
Work History
HEDIS Consultant
CVS/Atena
01.2023 - 05.2025
- Audit/over-read of the medical record collection and review process for HEDIS quality reporting.
- Ensures accurate and complete documentation of required information to meet risk management, regulatory, and accreditation requirements.
- Evaluated client needs and expectations, establishing clear goals for each consulting engagement..
- Collaborated with cross-functional teams to successfully deliver comprehensive solutions for clients.
Clinical Quality Specialist
ULTIMATE HEALTH PLAN
09.2022 - 12.2022
- Responsible for Clinical Quality Management and HEDIS care gaps. Assist and manage with off-site chart mining for data collection for HEDIS and Star measures to close care gaps.
- Prepares Excel spreadsheets for IPA education on HEDIS and monthly meetings with IPA, hospital, SNF or health plan preferred. Making outreach calls to members for medication education on Diabetes, Hypertension and Cholesterol disease control.
- Enhanced team performance through regular clinical audits, identifying areas for improvement and implementing corrective actions.
- Assisted in accreditation efforts by preparing necessary documentation, coordinating site visits, and demonstrating organizational commitment to quality improvement.
- Implemented new electronic health record system to improve efficiency in collecting, storing, and analyzing patient data for informed decisionmaking.
Clinical HEDIS Auditor
UNITED HEALTH GROUP
01.2021 - 05.2022
- Contract with CSI agency. Responsible for HEDIS quality of read medical charts and obstruction. Assure quality control for HEDIS clinical guidelines and follow NCQA requirements. STARS measurements and quality driven. Multiple data collection reviews of quality medical management. Deliver high quality results and reports within the required timelines.
- Maintained confidentiality, handling sensitive information discreetly throughout all stages of the audit process.
- Provided detailed documentation on audit findings, facilitating swift corrective action when necessary.
- Ensured compliance with regulatory requirements by performing regular audits and staying up-to-date on industry standards.
- Streamlined audit processes, improving efficiency and reducing time spent on each audit engagement.
- Planned and executed follow-up audits at appropriate intervals.
Clinical Quality Documentation Specialist
NUANCE COMMUNICATION
08.2021 - 01.2022
- Provide documentation for health care providers including converting audio recordings encounter between the patients and the providers. Leveraging technology to summarize medical facts in professional clinical reports (History of Present Illness, Physical Exam, Results, Assessment & Plan).
- Achieve proficiency in navigating EHRs and enter clinical reports and data directly into customer EHRs, adhering to specific clinic guidelines and workflows.
- Collaborate with managers on feedback from providers and successfully resolve issues.
- Implemented a centralized document storage system, reducing retrieval time for critical information.
- Collaborated with departments across the organization to address complex documentation challenges effectively.
- Established strong relationships with internal clients to better understand their documentation needs.
Clinical HEDIS Specialist
ANTHEM BLUE CROSS
11.2020 - 04.2021
- Contracted through NFuzion.
- Followed all company policies and procedures to deliver quality work.
- Improved customer satisfaction rates through proactive problem-solving and efficient complaint resolution.
- Collaborated with cross-functional teams to achieve project goals on time and within budget.
Behavior Health Utilization Clinical Coordinator
THE WILLOUGH AT NAPLES
07.2020 - 10.2020
- Performed precertification function to gain approval for hospital admissions. Communicates verbally with managed care organizations to gain approval for continued stay. Prepared monthly reports. Interacts with physicians and health care staffs to maintain up to date clinical reviews with patients’ daily reviews. Performed daily new admissions, concurrent reviews and discharged patients reviews on a timely manner.
- Worked closely with clinic administrators to maintain a safe, clean and well-organized environment in which patients could receive care.
- Developed strong relationships with community partners to enhance support services available for patients beyond the clinical setting.
- Enhanced interdisciplinary collaboration through effective communication and coordination among healthcare team members.
Clinical HEDIS Specialist
ANTHEM HEALTH CARE
01.2019 - 05.2019
- Contracted through BCForward.
- Responsible for HEDIS quality of read medical charts and obstruction. Assure quality control for HEDIS clinical guidelines and follow NCQA requirements. STARS measurements and quality driven.
- Improved customer satisfaction rates through proactive problem-solving and efficient complaint resolution.
- Championed the adoption of new software tools that streamlined workflows across multiple departments.
- Conducted comprehensive competitor analysis to inform strategic decisions.
Clinical Delegation Oversight Coordinator
BLUE CROSS BLUE SHEILD
10.2018 - 12.2018
- Oversee clinical and medical annual report audits. Responsible for multiple audit tools, contracts and policies. Manage and perform audits of medical claims payments data to validate conformance with specified coverage policy and agreement. Select and prepare valid audit sample following the standard department policy and requirements. Ensure audit timelines are adhered to and deliver high quality results. Assist with claims data analysis and Quality Assurance as requested. Participate in team meetings and conferences with audit team as well as internal and external delegates as necessary.
- Entered data, generated reports, and produced tracking documents.
- Improved team productivity with regular communication and progress updates, fostering a collaborative work environment.
- Enhanced operational workflows by maintaining well-organized documentation systems and updating records accurately as needed.
Manager of Quality, Medical Management
FAMILY HEALTH NETWORK
09.2017 - 03.2018
- Contracted through Reliance One.
- Performed and monitored quality improvement efforts per management plans. Facilitated quality and performance improvement with providers and medical groups. Conducted, oversaw and monitored activities, delegating to groups and vendors, including data submissions, required reports, and audits. Ensured completeness and compliance with all documentation and records.
- Performed weekly and monthly reports, oversaw grievances and appeals, and case management.
- Oversaw appeals, grievances, quality of care cases, total revenue, claims analyst and reports.
- Performed HEDIS medical reviews and audits with CMS guidelines.
- Managed and motivated employees to be productive and engaged in work.
- Accomplished multiple tasks within established timeframes.
- Maintained professional, organized, and safe environment for employees and patrons.
Quality Intervention Specialist II
MOLINA HEALTH CARE
09.2016 - 05.2017
- Contracted through K-Force.
- Responsible for providing on-site clinical education to providers on HEDIS measures, P4P, Quality improvement measure. Communicated weekly with providers and scheduled visiting staff for audits. Engaged in reviews of research analysis of medical records.
- Built strong relationships with parents and guardians, fostering open communication regarding student progress and needs.
- Promoted a positive learning environment by incorporating social-emotional learning strategies into daily activities.
- Facilitated small group instruction for targeted skill development, enhancing academic growth for all participants.
Case Management Coordinator
CIGNA HEALTH-CARE
11.2015 - 11.2015
- Collaborated with interdisciplinary teams to develop comprehensive care plans tailored to individual needs.
- Reviewed and developed intake and discharge planning strategies to encourage client engagement and retention.
- Collaborated with multidisciplinary teams to facilitate client care and reduce case management barriers.
- Created care plans that addressed clinical and financial challenges, family requirements and facilitated patient quality of life.
Medical Auditor and Clinical Quality Assurance Analyst
HEDIS
06.2014 - 09.2015
- With experience in overseeing quality, medical improvement, HEDIS, reporting, grievances/appeals, case management, retrieving/auditing records, and bridging quality gaps.
- Facilitated quality and performance improvement with providers and medical groups.
- Conducted, oversaw and monitored activities, delegating to groups and vendors, including data submissions, required reports, and audits.
- Reviewed and audited medical charts for quality assurance of medical codes as a HEDIS Project Specialist.
Medical Interpreter
INDEMAND INTERPRETING
04.2012 - 04.2014
- Responsible for video medical interpreting between health care providers and non-English speaking patients. Facilitated communication between multiple health care settings including emergency room, critical care and surgical procedures.
- Maintained strict confidentiality, adhering to HIPAA guidelines while handling sensitive medical information during the interpretation process.
- Followed ethical codes to protect confidentiality of patient medical information.
- Supported healthcare professionals in delivering accurate diagnoses by effectively interpreting detailed medical histories from non-English speaking patients.
- Enhanced patient understanding by accurately translating medical terminology and complex concepts between medical professionals and patients.
Education
M.D. - Medicine
St. Mary' School of Medicine South Pacific
South Pacific12.1999
MBA - Business Administration
Illinois Institute of Technology
Chicago, Illinois12-1993
Bachelor of Science - Biology
Lewis University
Romeoville, Illinois05.1990
Skills
- HEDIS performance evaluation
- Managed healthcare services
- Knowledge of NCQA standards
- CPT code proficiency
- Clinical management proficiency
- Proficient in EMR software
- Workflow optimization
- Quality assurance management
- Healthcare collections management
- Cultural interpretation
- Critical thinking and analysis
- Detailed knowledge of anatomy
- Experienced in ICD coding practices
- Proficient in ICD-9 classification
- Understanding of HIPAA regulations
- Strong technical computer skills
- Effective problem resolution
- Strong attention to detail
- Leadership and mentoring
- Client engagement
- Strong ethical standards
- Proficient in MS Office
- Data-driven decision making
- Organizational strategy development
- Effective troubleshooting abilities
- Customer engagement strategies
- Effective project management
- Effective goal development
- Engaging presentation skills
- Effective time management
- Client relationship management
- Project planning and prioritization
- Process optimization
- Building client relationships
- Project coordination
- Quality assessment
- Data analysis
- Application of industry best practices
- Organizational growth strategies
- Operational efficiency analysis
- Global awareness
- Data forecasting
- Project timeline creation
Accomplishments
- Achieved closing quality gap through effectively helping with improving quality scores.
- Documented and resolved issue which led to STARS 5 ratings.
- Used Microsoft Excel to develop inventory tracking spreadsheets.
- Achieved reduce compliance risks by completing medical charts audit with accuracy and efficiency.
Certification
- ECFMG Graduated Foreign Physician Certification. Present
- Advance Physician Medical Monitor Clinical Research Certificate APMMC PROFESSIONAL 2022. Present
Languages
Chinese (Cantonese)
Native or Bilingual
English
Full Professional
ECFMG certification
Foreign medical graduates passes USMLE 1 & USMLE 2
Timeline
HEDIS Consultant
CVS/Atena
01.2023 - 05.2025
Clinical Quality Specialist
ULTIMATE HEALTH PLAN
09.2022 - 12.2022
Clinical Quality Documentation Specialist
NUANCE COMMUNICATION
08.2021 - 01.2022
Clinical HEDIS Auditor
UNITED HEALTH GROUP
01.2021 - 05.2022
Clinical HEDIS Specialist
ANTHEM BLUE CROSS
11.2020 - 04.2021
Behavior Health Utilization Clinical Coordinator
THE WILLOUGH AT NAPLES
07.2020 - 10.2020
Clinical HEDIS Specialist
ANTHEM HEALTH CARE
01.2019 - 05.2019
Clinical Delegation Oversight Coordinator
BLUE CROSS BLUE SHEILD
10.2018 - 12.2018
Manager of Quality, Medical Management
FAMILY HEALTH NETWORK
09.2017 - 03.2018
Quality Intervention Specialist II
MOLINA HEALTH CARE
09.2016 - 05.2017
Case Management Coordinator
CIGNA HEALTH-CARE
11.2015 - 11.2015
Medical Auditor and Clinical Quality Assurance Analyst
HEDIS
06.2014 - 09.2015
Medical Interpreter
INDEMAND INTERPRETING
04.2012 - 04.2014
M.D. - Medicine
St. Mary' School of Medicine South Pacific
MBA - Business Administration
Illinois Institute of Technology
Bachelor of Science - Biology
Lewis University
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