HOMAIRA MARDANZAI
Summary
With over 20 years of healthcare leadership experience, strategic and results-driven professional. Worked in skilled nursing facilities, hospitals, and managed healthcare organizations. Expertise in compliance, payment integrity, claims operations, capitation expense, and health plan delegation audits and oversight. Deep knowledge of CMS, DMHC, DHCS regulatory requirements, and payment guidelines. Excel at leading high-profile projects and optimizing processes for operational efficiency and risk mitigation. Collaborative leader with strong background in cross-functional team management, regulatory audits, and process improvement initiatives for excellence in healthcare administration.
Overview
18
18
years of professional experience
Work History
Director of Rework and Payment Programs
Optum
04.2024 - Current
- Oversee compliance and payment integrity initiatives, ensuring adherence to CMS policies, DMHC, DHCS requirements, and health plan regulations for claim and rework operations
- Provide strategic oversight of claims operations, claims quality audit, rework, capitation expense, health plan delegation, and compliance-related activities
- Manage high-profile projects to enhance regulatory compliance and payment integrity, improving operational efficiency and mitigating financial risks
- Lead cross-functional teams in streamlining claims payment processes, enhancing provider relations, and reducing payment discrepancies
- Drive process improvement initiatives by analyzing claims data, identifying payment inconsistencies, and implementing corrective action plans
- Conduct internal audits, ensuring compliance with health plan guidelines and industry regulations
- Provide training and mentorship to staff on regulatory updates and best practices in payment integrity
Director, Configuration and Payment Programs
Optum
03.2023 - 04.2024
- Provide strategic oversight of system configuration and payment programs, ensuring accurate execution of DOFR, benefits, provider additions, and fee schedule loads
- Lead the implementation and optimization of a pricing system, collaborating with vendors to align with CMS, MediCal payment, and pricing policies for accurate reimbursement
- Manage and oversee monthly Prop 56 operations, working closely with IT, finance, and the health plans to ensure payments comply with DHCS guidelines
- Oversee capitation expense management, ensuring seamless execution of contractual changes through stakeholders collaboration
- Partner with cross-functional teams to enhance system operations, ensuring compliance with regulatory requirements and contractual obligations
- Enhanced team collaboration through regular communication, goal setting, and performance evaluations.
Director, Compliance & Payment Integrity
Optum
02.2021 - 03.2023
- Oversight of health plan audits and delegation oversight, ensuing regulatory compliance and adherence to contractual requirements
- Oversight of PDR/rework team to ensure accurate PDR resolution and dispute management
- Developed and monitored key performance indicators (KPIs) to assess operational efficiency, compliance, and payment accuracy
- Established metrics-driven performance monitoring for health plan audits, delegation oversight, and compliance initiatives
- Led data-driven decision-making by implementing dashboards and reporting tools to track PDR resolutions, claims accuracy, and financial performance
- Oversight of Member Out-Of-Pocket Max (MOOP) workflow as well as complex and high dollar claims to ensure proper flagging and adjudication of claims
- Managed mailroom operations, optimizing workflows to improve efficiency and compliance in handling claims-related documentation
Associate Director, Compliance & Regulatory
Optum
02.2019 - 02.2021
- Developed audit readiness strategies to ensure operational alignment with regulatory guidelines
- Oversight of direct CMS, DMHC, and DHCS audits, coordinating audit responses, corrective action plans, and compliance reporting
- Led teams of up to 45 personnel, supervising daily, monthly performance as well as training and improvement plans.
- Fostered a culture of continuous improvement by encouraging staff to share innovative ideas and providing resources for professional development.
- Prioritized tasks and allocated resources appropriately to keep teams focused and productive.
- Assisted senior leadership in managing all aspects of operations.
Manager, Compliance & Regulatory
Monarch HealthCare
10.2015 - 02.2019
- Developed and implemented ODAGs and MTRs, ensuring compliance with regulatory and health plan specific requirements
- Automated ODAG processes, tailoring configurations to meet the unique requirements of each health plan to promote accuracy and efficiency
- Provided oversight of all health plan and regulatory audits, coordinating responses and corrective actions to maintain compliance
- Led the PDR and Claim Quality Audit teams, optimizing workflows and enhancing work queues to improve efficiency and accuracy
- Spearheaded process improvement initiatives, significantly reducing turnaround time (TAT) for PDR resolution
- Managed and motivated employees to be productive and engaged in work.
Associate Business Analyst
Monarch Healthcare
02.2015 - 09.2015
- Project lead for ICD-10 initiatives, ensuring seamless transition and compliance with new coding regulations
- Managed testing activities to verify ICD-10 readiness across multiple applications and processes
- Coordinated work efforts between Business Operations and other functional teams for OneCare Connect implementation
- Led benefit administration workgroups, streamlining processes to enhance efficiency and regulatory compliance
- Conducted audits and prepared reports for CMS compliance, ensuring successful audit outcomes
Lead, Capitation and Eligibility
Monarch Healthcare
05.2008 - 02.2015
- Managed the redesign of the Specialty Capitation system, optimizing business rules to promote efficiency
- Provided oversight for capitation payments, ensuring accuracy in financial disbursements and compliance with contractual agreements
- Trained and mentored staff on best practices in capitation, claims processing, and regulatory compliance
- Led process improvement initiatives, resulting in enhanced accuracy and reduced provider disputes
Capitation Specialist II
Monarch Healthcare
01.2007 - 04.2008
- Processed and analyzed monthly capitation payments for specialty providers
- Collaborated with claims, contracting, and network management teams to resolve provider payment issues
- Maintained provider databases, ensuring accurate tracking of payment distributions
Education
Master of Business Administration -
University of Phoenix
Saddleback, CA12.2005
Certificate in Health Service Management -
Indiana University-Purdue University
Indianapolis, IN12.2003
Bachelor of Science - Health Administration and Management
Indiana University
Bloomington, IN05.2002
Skills
- Strong knowledge of CMS, DMHC, DHCS regulations, ensuring compliance and operational alignment
- Exceptional communication and collaboration skills, effectively engaging with cross-functional teams, stakeholders, and regulatory bodies
- Strong interpersonal skills, fostering effective collaboration and engagement
- Excellent problem solving and critical thinking abilities, driving efficient solutions to complex operational challenges
- Strong knowledge of Ez-Cap, Burgess Source
Timeline
Director of Rework and Payment Programs
Optum
04.2024 - Current
Director, Configuration and Payment Programs
Optum
03.2023 - 04.2024
Director, Compliance & Payment Integrity
Optum
02.2021 - 03.2023
Associate Director, Compliance & Regulatory
Optum
02.2019 - 02.2021
Manager, Compliance & Regulatory
Monarch HealthCare
10.2015 - 02.2019
Associate Business Analyst
Monarch Healthcare
02.2015 - 09.2015
Lead, Capitation and Eligibility
Monarch Healthcare
05.2008 - 02.2015
Capitation Specialist II
Monarch Healthcare
01.2007 - 04.2008
Certificate in Health Service Management -
Indiana University-Purdue University
Bachelor of Science - Health Administration and Management
Indiana University
Master of Business Administration -
University of Phoenix
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