ELSA IRIS BORRERO ORTIZ
Clermont,Florida
Summary
Seasoned Account Executive Manager with comprehensive background in account management, strategic planning and business development. Demonstrated skills in leading teams to exceed sales targets while maintaining high levels of client satisfaction. Exceptional ability to cultivate relationships, identify opportunities, and provide tactical business solutions. Notable impact made by implementing innovative strategies that increased overall productivity and team efficiency.
Overview
12
12
years of professional experience
Work History
Account Executive Manager
Florida Accountable Care Services
Winter Park, Florida
08.2021 - 09.2024
- Performed regular audits of provider contracts to ensure accuracy of data in the system.
- Provided guidance on contract language, policy interpretation and reimbursement procedures to providers.
- Negotiated terms for new contracts with providers while ensuring that company policies were adhered to.
- Analyzed trends in provider utilization and cost containment initiatives to identify areas for improvement.
- Assisted providers in understanding their contractual obligations and ensured timely resolution of any discrepancies or disputes.
- Identified opportunities for process improvements related to provider relations activities.
- Monitored changes in relevant regulations, government legislation and industry standards affecting provider relations activities.
- Conducted site visits to evaluate current processes used by contracted providers including medical record review and quality assurance measures.
- Coordinated internal training sessions on topics such as coding updates, claims processing guidelines.
- Collaborated with other departments within the organization to resolve complex issues related to provider relations activities.
- Maintained accurate records of all communications with providers including emails, letters, phone calls.
- Responded quickly and effectively to complaints from contracted providers regarding payment issues or other matters.
- Facilitated meetings between senior management personnel and external stakeholders such as payers or regulatory bodies.
- Assisted in the development of marketing materials highlighting products and services offered through contracted providers.
- Investigated concerns such as billing and claims questions on behalf of providers.
- Cultivated strong relationships to maintain provider network knowledge and implement corrective actions for ongoing issues.
- Researched and developed provider network strategies to ensure compliance with contractual obligations.
- Developed and maintained strong relationships with providers by responding promptly to inquiries, resolving issues and providing ongoing support.
- Stayed current on available policies and plans.
Credentialing Coordinator
Florida Accountable Care Services
Winter Park , Florida
08.2021 - 09.2024
- Reviewed and processed applications to verify accuracy of credentialing information.
- Created and maintained records for all providers in accordance with the organization's standards.
- Monitored and tracked progress of credentialing applications to ensure timely completion.
- Responded to inquiries from internal and external sources regarding credentialing status.
- Maintained database of provider information, including contact details and licensure expiration dates.
- Coordinated with departments within the organization to facilitate smooth completion of credentialing process.
- Collaborated with other organizations to obtain required documents for verification purposes.
- Assisted in preparing reports related to provider data and credentialing activities.
- Provided guidance and advice to providers on the credentialing process.
- Offered high level of assistance during managed care auditing process and conducted internal file audits.
- Maintained informational resources, tracking and documenting requests for updates, certification and credentialing.
Medicare Risk Adjuster
Florida Accountable Care Services
Winter Park, Florida
08.2021 - 09.2024
- Reviewed medical records to identify and code diagnoses in accordance with ICD-10 guidelines.
- Documented risk adjustment codes into electronic health record systems, ensuring accuracy of data entry.
- Evaluated patient charts for completeness, accuracy and compliance with applicable rules and regulations.
- Assisted physicians in the identification of appropriate diagnosis codes based on documentation in the medical record.
- Analyzed provider documentation to ensure accurate coding of diagnoses and procedures according to CMS Medicare Risk Adjustment Coding Guidelines.
- Performed quality assurance audits for assigned providers for coding accuracy and completeness.
- Conducted chart reviews to identify any missing or incomplete information necessary for accurate coding.
- Provided education and training to providers regarding coding guidelines and reimbursement policies as needed.
- Compiled reports summarizing findings from risk adjustment activities, such as audit results or trends in coding practices.
- Collaborated with other departments to ensure correct coding of services rendered by providers.
- Maintained current knowledge of changes related to ICD-10, CPT and HCPCS codes, modifiers, CMS regulations.
- Researched new insurance plans to understand their specific requirements for risk adjustment coding.
- Developed process improvements within the department in order to increase efficiency and accuracy of workflows.
- Created educational materials related to risk adjustment topics for use by providers or staff members.
- Maintained positive working relationship with fellow staff and management.
Clinical Administrator
JC Medical Center
Orlando, Florida
01.2021 - 08.2021
- Managed day-to-day operations of the clinical office, including scheduling appointments, managing patient records and billing.
- Maintained a clean and organized workspace to ensure efficient workflow.
- Coordinated with other departments to provide excellent customer service and facilitate smooth functioning of the office.
- Ensured compliance with all applicable regulations, policies, procedures and standards.
- Developed strategies for improving operational efficiency and optimizing workflow processes.
- Provided guidance and support to staff regarding daily tasks, job responsibilities and goals.
- Tracked patient progress data to monitor quality of care provided by the clinic.
- Conducted regular performance reviews with staff members to ensure optimal productivity levels were maintained.
- Analyzed medical records for accuracy and completeness prior to filing or submitting them for reimbursement purposes.
- Monitored inventory levels of supplies used in the clinic on a regular basis.
- Created weekly and monthly reports on key performance indicators related to the clinic's operations.
- Responded promptly to inquiries from patients, vendors or other stakeholders.
- Prepared documents necessary for insurance claims processing.
- Developed training materials for new employees on proper use of equipment or software programs.
- Participated in various committees related to healthcare administration or policy making.
- Served as a liaison between the clinical office and other medical facilities when needed.
- Supervised front desk to manage check-ins and check-outs, verify insurance and collect payments.
- Managed PTO by approving, denying and processing requests.
- Verified and administered employee timesheets to maintain accurate payroll.
- Checked on employee work regularly to verify compliance with OSHA, HIPAA and office-specific standards governing quality patient care.
- Established work procedures or schedules to organize daily work of administrative staff.
- Monitored office supplies to replenish needed inventory before depletion.
- Worked with management team to improve workflows and eliminate unnecessary tasks.
- Coordinated and conducted classes to teach procedures to new staff members.
- Created and revised systems and procedures by analyzing operating practices, recordkeeping systems and forms control.
- Managed busy calendar for executive team, planning and preparing meetings and communications.
- Pitched in to help with office tasks during busy periods and staff absences.
- Created and implemented administrative processes and procedures to prioritize job tasks and establish personnel responsibilities.
- Analyzed internal processes and recommended and implemented procedural or policy changes to improve operations.
Clinical Risk Management
JC Medical Center
Orlando, Florida
01.2021 - 08.2021
- Conducted risk management processes to identify, analyze, and mitigate risks.
- Advised management on potential risks associated with unresolved billing disputes.
- Provided training on best practices related to internal controls, financial reporting, risk management.
- Developed pipeline inspection plans and risk management strategies for pipelines.
- Collaborated with management teams to develop strategies for minimizing risks associated with hazardous material exposure.
- Evaluated risk management processes and procedures to identify potential weaknesses or vulnerabilities in the organization's operations.
- Developed and implemented risk management strategies to identify, assess, monitor, and mitigate risks.
- Initiates, coordinates, and manages all investigational.
- Evaluation activities associated with professional liability occurrences.
- Including conducting interviews.
- Researching and reviewing policies and procedures.
- Reviewing of electronic medical record documentation and other information sources
Nurse Procedure
South Lake Gastroenterology
Clermont , Florida
11.2020 - 01.2021
- Assessed and monitored patient health conditions, including vital signs such as temperature, pulse rate and blood pressure.
- Provided nursing care for patients with various medical diagnoses and treatments.
- Collaborated with other healthcare professionals to develop individualized plans of care for each patient.
- Ensured that all documentation was accurate and up-to-date according to established guidelines.
- Educated patients on their medical condition, treatment plans, and self-care management techniques.
- Performed physical assessments to identify any changes in the patient's condition or needs.
- Assist Physician on procedure, Anal Manometry, Hemorrhoids Ligation, Pylori Breathing Test, Liver scan, Endo-Capsule.
Assistant Clinical Manager
Saint Peter Medical Group
Kissimmee, Florida
05.2020 - 10.2020
- Collaborated with other healthcare professionals to develop treatment plans for patients.
- Provided support to nursing staff by providing guidance on patient care issues.
- Maintained accurate records of patient visits, treatments, medications, and outcomes.
- Collaborated with healthcare professionals to deliver high-quality patient care.
- Interviewed applicants and made recommendations for new hires.
- Communicated with patients with compassion while keeping medical information private.
- Maintained records management system to process personnel information and produce reports.
HEDIS Manager
Premier Physicians Support
Orlando, Florida
09.2017 - 04.2020
- Created monthly reports for senior management summarizing operational performance metrics.
- Coached, mentored and trained team members in order to improve their job performance.
- Conducted regular meetings with staff to discuss progress and identify areas of improvement.
- Resolved conflicts between employees by providing guidance on company policies and procedures.
- Reviewed medical records to ensure accuracy and completeness of data according to HEDIS specifications.
- Developed and maintained detailed knowledge of all HEDIS measures and protocols.
- Conducted chart reviews for quality assurance purposes, ensuring compliance with HEDIS standards.
- Created reports summarizing findings from the review process, including any discrepancies or errors identified.
- Analyzed results from various healthcare databases to identify opportunities for improvement in care delivery processes and outcomes.
- Performed regular audits of medical records using established criteria to measure performance against quality standards set by regulatory bodies such as NCQA.
- Provided feedback on physician documentation practices to ensure that they are compliant with applicable regulations and guidelines, including those set forth by The Joint Commission.
- Communicated regularly with physicians regarding best practices in documentation and patient care coordination.
- Documented all necessary information into appropriate systems in order to track progress towards meeting quality goals.
- Developed and delivered training programs for health information technology, creating operating manuals.
MRA/HEDIS Field Reviewer
Premier Medical Associates
Lady Lake, Florida
10.2013 - 12.2014
- Generated detailed reports on findings related to HEDIS standards.
- Assessed the validity of submitted claims against applicable regulations and standards.
- Communicated with healthcare personnel to verify information and resolve issues as needed.
- Compiled statistical reports summarizing audit results for management review.
- Conducted comprehensive review of medical records for HEDIS compliance.
- Researched and clarified coding discrepancies in accordance with established guidelines.
- Provided technical assistance to providers regarding HEDIS documentation requirements.
- Identified potential areas of improvement in provider performance related to HEDIS measures.
- Monitored progress towards completion of assigned tasks within designated timeframes.
- Reviewed medical records for completeness, accuracy, timeliness, and appropriateness of care.
- Developed strategies for improving provider performance related to quality initiatives.
- Participated in training sessions aimed at increasing understanding of HEDIS protocols.
- Attended meetings with staff members to discuss best practices related to HEDIS measures.
- Performed audits on a regular basis in order to assess adherence with applicable standards.
Clinical Care Coordinator
Urban Health Plan
Clermont , Florida
09.2012 - 10.2013
- Organized, coordinated and monitored patient care services to ensure efficiency and quality.
- Developed and implemented clinical protocols for the management of chronic diseases.
- Provided case management services including assisting with referrals, authorizations, eligibility verification, and benefits coordination.
- Monitored changes in patients' medical conditions and made necessary adjustments in treatment plans according to physician's orders.
- Assisted with developing short-term goals based on identified needs while working towards long term objectives established by the patient's physician.
MRA/HEDIS Field Reviewer
Urban Health Plan
Clermont, Florida
09.2012 - 10.2013
- Generated detailed reports on findings related to HEDIS standards.
- Assessed the validity of submitted claims against applicable regulations and standards.
- Communicated with healthcare personnel to verify information and resolve issues as needed.
- Compiled statistical reports summarizing audit results for management review.
- Conducted comprehensive review of medical records for HEDIS compliance.
- Gathered, evaluated and interpreted data from various sources to ensure accuracy.
- Researched and clarified coding discrepancies in accordance with established guidelines.
- Provided technical assistance to providers regarding HEDIS documentation requirements.
- Identified potential areas of improvement in provider performance related to HEDIS measures.
- Analyzed data to identify trends and patterns that may impact quality metrics.
- Monitored progress towards completion of assigned tasks within designated timeframes.
- Documented observations, identified deficiencies, and provided recommendations for improvement.
- Participated in training sessions aimed at increasing understanding of HEDIS protocols.
- Attended meetings with staff members to discuss best practices related to HEDIS measures.
- Performed audits on a regular basis in order to assess adherence with applicable standards.
- Provided feedback about audit processes in order to improve overall efficiency.
- Enhanced electronic records management systems to meet new needs and forecasted demands.
- Met needs of physicians and other treating team members with timely retrievals of patient medical records.
Education
M.D. -
Universidad Autonoma De Guadalajara
Guadalajara 06-2010
Bachelor of Science - Microbiologia Industrial
Universidad De Puerto Rico
Mayaguez06-2005
Skills
- Territory Management
- Strategic Planning
- New Hire Onboarding
- Account Management
- Operations Management
- Marketing Strategy Development
- Staff Supervision
- Client Relationship Management
- Team building
- Team Collaboration
- Staff Training and Development
- Teamwork and Collaboration
Languages
English
Professional
Spanish
Professional
Skills and Training
- Fibro Scan, pH test, ARM, Pylori breathing test, DPN, ABI Flow Check, Respiratory therapy, Spirometry, PFT, Care Management, EKG, Pt-INR, OSHA, HIPPA, BLS, CPR, Multiple EMR software, ICD9& ICD10, CAQH, PECOS,
Timeline
Account Executive Manager
Florida Accountable Care Services
08.2021 - 09.2024
Credentialing Coordinator
Florida Accountable Care Services
08.2021 - 09.2024
Medicare Risk Adjuster
Florida Accountable Care Services
08.2021 - 09.2024
Clinical Administrator
JC Medical Center
01.2021 - 08.2021
Clinical Risk Management
JC Medical Center
01.2021 - 08.2021
Nurse Procedure
South Lake Gastroenterology
11.2020 - 01.2021
Assistant Clinical Manager
Saint Peter Medical Group
05.2020 - 10.2020
HEDIS Manager
Premier Physicians Support
09.2017 - 04.2020
MRA/HEDIS Field Reviewer
Premier Medical Associates
10.2013 - 12.2014
Clinical Care Coordinator
Urban Health Plan
09.2012 - 10.2013
MRA/HEDIS Field Reviewer
Urban Health Plan
09.2012 - 10.2013
M.D. -
Universidad Autonoma De Guadalajara
Bachelor of Science - Microbiologia Industrial
Universidad De Puerto Rico
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