Kenyatta Johnson

• Available for DRA guidance and questions regarding dispute review, work instruction adherence as it applies to the IDR process.
• Ensuring turn-around-times (TAT) are met under DRA review to stay within contractual agreements as an IDR entity with regard to oversight bodies which include Departments of Treasury, Labor and HHS Health and Human Services collectively.
• Always available to help enhance the teams skills and knowledge base especially according to the work instructions.
• Ensuring with high priority that PQLs are answered within a reasonable timeframe so as to not interfere with the dispute process TAT.
• Passing quality metrics individually and as a team to drive continuous improvement plans with the intentions to meet and exceed performance metrics.

• Reviewed completed IDR disputes after decision of eligibility or not by DRA for compliance adherence as mandated by CMS guidelines in the IDR setting.
• Ensured that adequate documentation was received by both parties in order to process the IDR request for a final decision.
• Ensured compliance measures are met with accuracy according to the guidelines and regulations set forth by CMS.
• Objectively and accurately recorded my findings into the QA tool for reporting purposes.
• Payed close attention to detail and utilized my ability to analyze data and all documentation for errors or non-compliance which correctness is mission -critical .

⦁ Hedis time sensitive project from January 2023-April 2023
⦁ Responsible for providing administrative and telephonic support for department working on a data collection project in a fast paced environment in order to meet deadlines within the project.
⦁ Worked under the direction of the Lead to assist and fulfill requests by contacting and corresponding with provider practices.
⦁ A high degree of professionalism and team effort was employed throughout the project.
⦁ Worked at a fast pace in EMR pursuit as the Hedis Service Associate II for medical record information, maintain department tracking log, and Abstractor calendars.
⦁ An understanding of the Medical record filing system within the department .
⦁ Responsible for assist abstractors by utilizing research within the company's claims and medical record systems and locating where members received care.
⦁ A high degree of professionalism and confidentiality was required and employed daily.
⦁ High level of familiarity with medical terminology, customer service, call center background and prior HEDIS experience was given priority for this position.

• Chart review utilizing HEDIS/ STARS Measures in Commercial/Government sectors.
• Participated in claims discussion meetings with claims examiners and supervisors to review complex claims.
• Maintained monthly metrics tracking designated activities.
• Determined whether claims examiners or management questions could be appropriately addressed or referred to other team members.
• Medicare Appeals case review for medical necessity.
• Daily goal to meet and exceed government mandated timelines.
• Daily compliance with TAT Medicare D and Med B.
• Navigated multiple computer software applications.
• Chart review prescription on insurance plan formulary for over 2000 medications.
• National Plan and Provider Enumeration System (NPPES)

• Benefits processing of COVID-19 employee claims pay out due to COVID-19 related illnesses.
• Contact Tracing follow-up with affected case subject.
• Case metrics reporting.
• Salesforce CRM platform proficiency.
• Omni-Channel Salesforce.
• Panorama CRM platform experience.

• Hybrid Role: Worked under the direction of the Corporate Medical Director and Site Project Director to onboarding of new Physicians and PHD level reviewers in Behavioral Health chart review assignment in both disciplines for timely completion for contract compliance. ▪ Ensured adequate chart reviews were assigned for provision of timely review completion. ▪ Daily communication with Physician Reviewers and have been the liaison needed to exceed expectations in chart review for medical necessity, more recently for COVID-19 hospital visits. ▪ Ensured completion of required Physician onboarding process. Included but not limited to virtual Physicians Systems and software training and credentialing. NPI updates and MES Peer Review Services for cross-state licensing.
  ▪ Served as a super user for adverse outcome chart reviews and as technical support for Physicians for medical reviews and Behavior Analysis Programs as well. ▪ Forward driven pro forma initiatives while well versed in delivering Data Analytics into Strategy & operational improvements both written and oral. ▪ Served as a liaison between Utilization Management & Corporate C-Suite members. ▪ Strategic planning of locum and assign charts as needed.
  ▪ Maintained and established departmental policies and procedures, objectives and standards assuring site compliance with AHCA state regulations/requirements. Denials and Appeals Management-
  
  ACHA Fair Hearings scheduling and final court abstract follow-up.
• AHCA complaint resolution.

• Customer Service Team Lead Florida and Colorado Contracts–2016-2018 Provided mentorship and training.
• Daily call monitoring for quality assurance as to support the pillars of company values and mission statement.
• Maintained knowledge of job descriptions, performed employee monthly evaluations.
• Human resource management of new customer service reps. Goal setting and monthly evaluations of 17-24 customer service representatives.
• Provider portal -interface troubleshooting.
  
• Generated reports detailing metrics such as call times and satisfaction ratings and Quality Assurance.

• 50 Outbound Calls per day to Medicaid recipients to conduct EPSDT home surveys and close gaps in care for care coordination of services- Illinois Contract.

• Lawson Computer Software for accurate shipping of hospital supply procurement.
• Administrative duties include front office employee time keeping and payroll management reconciliation.

• Conduct Tours daily and sold rental spaces of the 20,000 sq ft meeting venue to possible clients ranging from $1000-$3000 per/hr in positive revenues for the facility.
• Reconciliation of monthly banking account statements receivable & accounts payable.

• Assisted Federal Employees refill their prescriptions via rapid incoming call center and PBM Management Software and multiple platforms.40-70 incoming call handling/day
• Third-Party billing re-imbursement
• Prior authorization follow-up

• Supervision of 2-7 employees in a customer service environment.
• End of day metrics reporting.
• Created marketing campaigns for advertising monthly.
• Inventory management and audits.
• Vendor management; recorded, tracked and monitored inbound supplies.