Karishma Patel
Pooler,USA
Summary
Experienced healthcare professional with a strong background in value-based care frameworks, including MSSP, ACOs, MIPS, NCQA, and HEDIS. Proven ability to drive performance improvements through data analysis, strategic planning, and cross-functional collaboration. Skilled in provider relations, quality measure tracking, and operational leadership, with a consistent record of enhancing clinical outcomes and organizational efficiency.
Overview
15
15
years of professional experience
1
1
Certification
Work History
Provider Relationship Specialist
Astrana Health
10.2024 - Current
- Track and monitor MSSP, ACO, ACO REACH, and Medicare Advantage Plan quality data and utilization.
- Present monthly quality improvement reports to physicians and staff, using collected data.
- Facilitate practice redesign efforts to enhance population health management and improve outcomes.
- Conduct onboarding, orientation, and ongoing training for provider compliance throughout the year.
- Develop trusted relationships with providers through regular in-person visits, emails, and calls.
- Provide on-site and remote assistance to clinicians and care teams to boost efficiency.
- Create detailed reports of provider visits, inquiries, trainings, and growth opportunities.
- Collaborate with departments to resolve provider inquiries promptly and effectively.
Practice Transformation Coach
Centene | Collaborative Health Systems
Georgia
09.2022 - Current
- Tracked and monitored MSSP ACO utilization and quality measure data monthly.
- Presented quality improvement reports to physicians and staff based on analyzed data.
- Recommended and implemented interventions to enhance clinical quality and operational efficiency.
- Collaborated with practices to facilitate redesign efforts and support population health management initiatives.
- Provided on-site and remote assistance to clinicians and care teams for improved practice efficiency.
- Developed and executed intervention work plans targeting quality measures and practice transformation.
- Optimized electronic health records, clinical documentation, billing practices, and financial performance reporting.
- Reviewed summary data and performance reports, including pay for performance and HEDIS metrics.
Ambulatory Quality Navigator (NCQA, and QPP)
St. Joseph's/Candler Medical Group
Savannah, GA
01.2020 - 09.2022
- Monitor and track MIPS/ ACO (QPP) and HEDIS, NCQA, Medicare Star Rating System Quality Measures Data and present it to, physicians, staff, and management for Clinical Quality improvement.
- Coach and train physicians, nurses, and other staff members on Quality Measures, HEDIS, and documentation.
- Conduct data analysis and validate data to ensure quality and accuracy of quality reports that can help improve physician performance on quality measures.
- Act as a liaison between payers and the organization to achieve quality goals (Aetna, Anthem, Optum, United Healthcare, and Well care).
- Collaborate with office managers to achieve optimal gap closures.
- Obtain care gap reports from various portals and close care gaps by uploading patient data to ensure optimal gap closures.
Office Manager II
St. Joseph's/Candler Medical Group
Savannah, GA
02.2016 - 01.2020
- Managed all aspects of a medical practice, including staff management, schedule coordination, financial reporting, and inventory management.
- Performed financial reporting and prepared daily reports on accounts receivable and record-keeping.
- Conducted medical billing and posted out-of-office charges in the EMR system for nursing homes and hospitals.
- Trained and coached staff in coding, billing, referral scheduling procedures, and authorizations.
- Served as the liaison between the billing department and physicians.
- Led monthly staff meetings to maintain consistent communication.
- Communicated and built business relations with suppliers and vendors.
- Constantly communicated with suppliers and sales representatives to ensure availability, purchase, and receiving of products.
- Resolved any patient complaints or concerns and provided actionable solutions.
- Ensured compliance with all state and federal rules and regulations.
Clerical Coordinator
St. Joseph's/Candler Medical Group
Savannah, GA
10.2012 - 02.2016
- Functioned as liaison between patients, clinical and clerical staff.
- Medical Billing: Generated claims for physicians working out of facilities.
- Assisted with billing claim correction.
- Managed secretarial, financial, and data entry duties in compliance with HIPAA.
Store Manager
Village BP
Pooler, GA
04.2010 - 10.2012
- Reconciled daily and monthly financial reports.
- Analyzed accounts payable/receivable reports to identify problems and implement solutions.
- Hired, trained, and supervised employees.
- Prepared purchase order with quantity based on demand.
- Constant communication with suppliers concerning the product, price, and delivery dates.
- Evaluated costs, Negotiated Price and contact, and Quantity discounts.
- Handled problems related to purchasing.
- Monitors supplier's performance and prepares reports.
- Handles issues regarding Customer service.
- Resolved problems related to purchasing, receiving, delivery and payment.
Education
Master of Business Administration -
Georgia Southern University
Statesboro, GA01.2017
Master of Healthcare Administration -
Georgia Southern University
Statesboro, GA01.2012
Bachelor of Science - Pharmaceutical Sciences
The Oxford College of Pharmacy
IndiaSkills
- Value-based care expertise: understanding of MSSP, ACOs, MIPS, HEDIS, NCQA, and Medicare Star Ratings
- Quality improvement strategies
- Data analysis and reporting
- Medical billing and coding
- Budgeting and financial oversight
- Supplier communication skills
- Provider relations expertise, business development
- Electronic health records
- Compliance training
- Performance reporting
- Staff training
- Provider onboarding
- Inventory management practices
- Price negotiation strategies
- Contract management proficiency
- Problem solving techniques
Certification
LEAN SIX SIGMA YELLOW BELT
Timeline
Provider Relationship Specialist
Astrana Health
10.2024 - Current
Practice Transformation Coach
Centene | Collaborative Health Systems
09.2022 - Current
Ambulatory Quality Navigator (NCQA, and QPP)
St. Joseph's/Candler Medical Group
01.2020 - 09.2022
Office Manager II
St. Joseph's/Candler Medical Group
02.2016 - 01.2020
Clerical Coordinator
St. Joseph's/Candler Medical Group
10.2012 - 02.2016
Store Manager
Village BP
04.2010 - 10.2012
Master of Business Administration -
Georgia Southern University
Master of Healthcare Administration -
Georgia Southern University
Bachelor of Science - Pharmaceutical Sciences
The Oxford College of Pharmacy
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