KIMBERLY SPEARS
Denham Springs,LA
Summary
Over 10 years of experience in Managed Care, Health insurance organizations, and Quality Management with expertise in HEDIS. Skills include analyzing large datasets such as administrative claims data and electronic health records, handling invoicing, data collection, abstraction, over-reads, medical records review, and auditing. Experienced in tracking trends, reviewing and analyzing reports for HEDIS, HEDIS ROADMAP process, provider/physician outreach, and vendor management. Proficient in working with HEDIS systems such as QSHR, Onbase, ILead, Iset, RateLift, Facets, and vendor systems like Altegra, Advantmed Cotiviti & CIOX. Technical skills include proficiency in Microsoft Word, Excel, PowerPoint Presentation, Outlook, Access, SAS, SSIS, SSRS, Tableau, SQL and CA Agile Central. Skilled in onsite provider/physician medical record chart collection, review, and abstractions. Expertise in Stars measures (HEDIS/CHAPS/HOS/med adherence), Optum program administration, use of plan tools, reports and systems. Strong ability to identify Quality Improvement or interventions opportunities and work cross-functionally to develop interventions or recommendations. Knowledge extends to regulatory standards including NCQA, CAHPS, HEDIS, CMS reporting compliance/HIPAA regulations. Well-versed in ICD-9 & ICD-10 coding and risk adjustment coding. Proficient in billing for commercial & governmental lines of business claims denials, medical collections adjudications. Experience with Medicaid Management Information Systems (MMIS), resolving EDI chargebacks and 837 EDI encounter files. Expertise also includes patient enrollment processes and understanding Diagnosis Related Group (DRG), Related Value Units (RVU), Ambulatory Payment Classification APCS as well as Appeals & Grievances. Background in project management and experience in payroll management budgeting accounting customer service academic credentialing grant writing document analysis data management within a structured fast-paced environment. Demonstrated ability to interpret and synthesize complex information accurately. Strong analytical and organizational capabilities to drive success in diverse roles.
Overview
24
24
years of professional experience
Work History
Quality HEDIS Abstractor Lll (contract)
CVS/Aetna
12.2023 - Current
- Reviewing medical records and documents to abstract clinical data for HEDIS reporting
- Integrating collected electronic and hardcopy data into reports
- Documenting findings in applicable HEDIS databases and on prescribed cloud-based platforms
- Meeting daily abstraction goals and maintaining a high abstraction accuracy percentage
- Performing on-site facility audits for compliance with HEDIS measures
- Preparing and presenting HEDIS compliance reports to health facility managers
- Training and advising healthcare professionals and administrative staff on HEDIS compliance
- Maintaining HIPAA standards and immediately reporting any critical findings to designated authorities
- Keeping abreast of HEDIS measures
- Enhanced communication with clients by providing timely updates on project status and addressing inquiries promptly.
- Expedited the completion of critical projects by prioritizing tasks effectively and efficiently utilizing available resources.
- Processed both outgoing and incoming requests for medical records from multiple sources.
Operation Director/Part Time
C.S. King Preparatory Academy
08.2014 - Current
- Coordinated technology implementation i.e., planning, procurement & training
- Compile data, review, and prepare management reports, manage & enforce service level agreement & contracts
- Develop & submit grant proposals for approval/renewal
- Successfully monitor a budget up to $3.5 million, successfully grant write and manage up to $500,000
- Manage accounts payable process including invoice approval, ensure accuracy of account posting
- Balance the gender ledger, oversee audits
- Manage all aspects of timekeeping/payroll including accurate preparation of payroll transmittal, ensure proper credentialing licensure are maintained
- Manage daily activities of designated staff; supervise after school program staff and Saturday school program/staff
- Interview and hire board members, school leadership, and assist with teacher’s selection process
- Confer with clients to determine objectives, budget, background information, presentation approaches, styles, and techniques
Quality Project Analyst Lead (contract)
Healthcare Support/United Healthcare Optum
12.2022 - 05.2023
- Exported MMR, vendor imports QSHR, QSI-XLadmin refresh updates, and flowchart imports
- Monitored internal data collection, maintained reports project LOB work files
- Install and configuration of Microsoft SQL, loaded QSHR data
- Maintained vendor import and admin refresh tracking system
- Granted system administration access
- Performed SQL backup and monitored vendor files on UCS shared drive
- Monitored project files in an ASP remote desktop environment
- Tracked ongoing project advancement towards predefined milestones, reducing instances of missed deadlines by 60%.
- Managed stakeholder expectations through transparent communication and regular updates, fostering trust and collaboration.
- Optimized testing protocols by integrating simulations into diagnostic and validation tasks.
- Reduced project timeline through effective resource allocation and task prioritization.
- Led implementation of project management software, enhancing team collaboration and project tracking capabilities.
Data Analyst (contract)
Diskriter Inc./Almeda Health System
12.2021 - 04.2022
- Successfully enhanced clinical quality improvement, patient safety, accreditation, public reporting, and performance incentives programs
- Inpatient psychiatric state of California seclusions and restraint monthly reporting
- CMS hospital inpatient, outpatient, psychiatric quality reporting and CMS risk adjustment submission data reporting
- Facilitated ongoing measurement, data optimization, reporting and information dissemination through data integrity, integration, standardization, analysis, and visualization
- Collaborated with multi-disciplinary teams and established guiding metrics along with benchmarks for performance improvements
- Provided clinical stakeholders data driven insights, worked closely with clinical stakeholders that produced highly relevant
HEDIS Abstractor (contract)
Randstad Healthcare/United Healthcare
12.2020 - 05.2021
- Identified appropriate information from medical records according to NCQA HEDIS Technical Specification and United Healthcare guidelines
- Reviewed medical records, abstract HEDIS data and other measure sets in compliance with standards
- Track and report issues outcomes related to abstractions and over-reads
- Communicated outcomes of abstraction and oversight activities with vendors
- Assisted in education of providers and staff on the use of clinical reporting tools
- Review and collect annual HEDIS audits and chart chases from health plans in collaboration with provider offices
(contract) Louisiana Healthcare Network
Totalmed/Quality Improvement Coordinator
09.2019 - 03.2020
- Conduct internal record reviews and audits, including medical records
- Reviewed records to ensure accuracy and compliance standards
- Initiate SOP revisions to ensure current and validated support continuous improvement
- Develop and enhance documentation, tracking tools and process flows for quality monitoring activities to comply with current regulations and standards
- Maintain databases and spreadsheets to track and trend quality monitoring activities, results, and outcomes
- Analyze data, develop reports to support quality improvement programs
- Monitored performance and optimized SQL queries for maximum efficiency
- Applied conditional formatting in SSRS to highlight key areas in the report data
HEDIS Quality Improvement Abstractor (contract)
Lancesoft Staffing
11.2018 - 05.2019
- Coordinated and prepared HEDIS medical records review, annual HEDIS medical records review
- Audited and educated provider on submitted medical records, monitored provider quality complaints
- Collect and analyze/summarized performances data to ensure timely accountability completion of state-mandated quality improvement opportunities
- Maintained 100% over-reads accuracy, provider invoicing, fax-mail medical records request, arranged provider onsite medical records request for assigned coworkers
- Provide weekly reports through Qualmetrix to identify gaps in care to develop interventions to help increase compliance and improve health outcomes
- Project Management: Maintained a systematic and robust provider audit to ensure all ESPDT services to enrollees under 21 years of age are timely according to required guidelines
- Implemented and managed oversight of internal medical records database, to ensure appropriate training of all individuals entering clinic data into medical records database and monitor quality assurance processes
- Converted Data Transformation Services (DTS) application to SQL Server Integrated Services (SSIS) as assigned
- Created reports using SQL Reporting Services (SSRS) for customized and ad-hoc Queries
- Created report snapshots to improve the performance of SSRS
HEDIS Clinical Quality Manager (contract)
Randstad Healthcare/United Healthcare
12.2015 - 05.2018
- Responsible for managing the Quality & Performance metrics for HEDIS in the Eastern Region those over the years encompassing Pennsylvania, Connecticut, DC, Virginia, Delaware, and Maryland Markets
- Assessed abstraction for all assigned markets, compared results to HEDIS standards or other measures sets, reviewed medical records & abstract data for HEDIS and other measures sets in compliance with standards
- Tracked report on outcomes issues related to abstractions, vendor invoicing, over-reads, contact & fax-mail
- Identified data gaps through data validation, tracking, resolution of any discrepancies in addition to examining provider records ensuring compliance with HEDIS & NCQA standards as needed for the Director
- Conducted all UHG HEDIS system trainings i.e., QSHR, Onbase, HTA, I-Lead, I-Set, and vendor system training Altegra & Advantmed
- & CIOX
- Developed and monitored updates programs and project plans, timelines and deliverables while coordinating and documenting
- HEDIS Quality Measures Technical Specifications: Controlling Blood Pressure (CBP), Cervical Cancer Screening (CCS), Immunization for Adolescents (IMA), Colorectal Cancer Screening (COL), Adult BMI Assessment (ABA), Activity for Children/Adolescents (WCC), Well-Child Visits in the Third, Fourth, and Sixth Years of Life (W34), Childhood Immunization Status (CIS), Comprehensive Diabetes Care (CDC), Prenatal and Postpartum Care (PPC), Care for Older Adults (COA)
- Medicare Stars Rating Measures: Osteoporosis Management, Reducing the Risk of Falling, Colorectal Cancer Screening, Annual Flu Shot, Getting Needed Care, Monitoring Physical Activity and Rheumatoid Arthritis
- Project scrub, provider specialty review for active chases, Quality Assurance of provider demographics, maintain medical records contacts
- Project Management Responsible for day-to-day implementation of national HEDIS improvement plan
- Executed projects including data collection of hybrids and administrative HEDIS data collection, medical records review, and auditing
- Analyze data chase and goals completion for measure per lines of business, collaborated with HEDIS manager to develop annual HEDIS project plans and monitor the HEDIS project plans for multiple line of business
- Outreach to provider office to obtain HEDIS data request along with verifying correct employment demographics and participated in vendor take-back
- Managed HEDIS lifecycle process for multiple plans, assisted in preparation for HEDIS audit, Developed and maintained HEDIS based report to support Quality initiatives
- Maintain data visualization and develop dashboards reports using Tableau, performed effective SQL Queries, designed, and developed various SSIS packages (ETL) to extract and transform data and involved in scheduling SSIS Packages
- Configured and deployed SSRS reports onto Microsoft Office SharePoint Server
- Vendor Management Utilized vendor management software for tracking and analyzing vendor performances
- Manage external vendor performance related to medical records data collections
- I.E., status of reviewer onsite date collection and retrieval, duplicate request
- Communicate with colleagues on changes within the market that may affect the demand for delivery of services
- Streamlined production processes by identifying areas for improvement and implementing corrective actions.
Medical Auditor, Revenue Analyst, Patient Account Representative
Our Lady of the Lake Regional Medical Center
04.2001 - 06.2015
- Audited Medical Records documentation to identify under-coded and up-coded services
- Provided second-level review of billing performances to ensure compliance with legal and procedural policies and ensure optimal reimbursements while adhering to regulations prohibiting unbundling and other questionable practices
- Researched, analyzed, and responded to inquiries regarding compliance, inappropriate coding, denials, and billable services
- Interacted with physicians and other patient care providers regarding billing and documentation policies, procedures, and regulations; obtains clarification of conflicting, ambiguous, or non-specific documentation
- Trained, advised, and provided technical support to medical providers and Medical Coding Analysts as appropriate regarding coding compliance documentation, regulatory provisions, and third-party payer requirements
- Analyzed monthly Appeals reports, track work effort by the billing vendor to ensure collections activity on a regular basis
- Analyzed weekly charges and payments data to ensure billing vendor is on track to meet established targets for productivity
- Reviewed EOBs as needed to determine/address payer issues
- Supervised/trained department staff as assigned by the manager and director as a Team Leader, supervised staff database for timely billing, denials, appeals process, and procedures are adhered to
- Supervised efforts regarding authorization issues in a timely manner
- Analyzed month end reports presented by billing vendor, identified opportunities for work process improvements with respect to claims denials
- Collaborated with divisional managers on strategies to improve front end related issues
- Responsible for pipeline of charge capture activities from encounter form development and review to correct coding and oversight for ensuring accurate reimbursement for services billed
- Responsible for driving process improvement initiatives related to front end revenue cycle functions, in collaboration with the operations leadership and divisional managers, assure all billing information timely across all divisions
- Collaborated with registration, scheduling, referral management, copay collection, self-pay collection, systems issues
- Facilitated credentialing process to assure prompt ability to bill for services rendered by newly hired physicians
- Abstract Medical Records to fulfill audit request required by NCQA HEDIS/CAHPS
- Facilitated and managed preseason HEDIS projects
- Administrative measurement and Medical Records review
- Assure accurate and timely HEDIS measurements of data
- Train providers HEDIS quality coding and quality billing Assist Insurance HEDIS request
- Primary and Secondary Biller for governmental and commercial insurance, medical denials, patient billing/invoicing and keying charges
- HIPPA, Compliance, NCQA/HEDIS/CAHPS, Trainer for new hires
Education
Bachelor of Science - Psychology
University of Phoenix
Phoenix, AZ12.2021
Skills
- Microsoft Word
- Excel
- PowerPoint Presentation
- Outlook
- Access
- SAS
- SSIS
- SSRS
- Tableau
- SQL
- CA Agile Central
- Onsite provider/physician medical record chart collection
- Review
- Abstractions
- Stars measures
- HEDIS
- CHAPS
- HOS
- Med adherence
- Optum program administration
- Plan tools
- Reports
- Systems
- Quality Improvement
- Regulatory standards
- NCQA
- CAHPS
- CMS reporting
- Compliance
- HIPPA
- ICD-9
- ICD-10 coding
- Risk adjustment coding
- Quality assurance
- Billing
- Commercial & governmental lines of business claims denials
- Medical collections
- Adjudications
- Medicaid Management Information Systems
- MMIS
- EDI chargebacks
- 837 EDI encounter files
- Patient enrollment
- Diagnosis Related Group
- DRG
- Related Value Units
- RVU
- Ambulatory Payment Classification
- APCS
- Appeals & Grievances
- Project management
- Payroll
- Budgeting
- Accounting
- Customer service
- Academic credentialing
- Grant Writing
- Records evaluation
- Communication skills
- Reporting and document management
- Record management
- Data management
- Conflict resolution
- Risk assessment
- Analytical skills
- Data interpretation
- Document analysis
Timeline
Quality HEDIS Abstractor Lll (contract)
CVS/Aetna
12.2023 - Current
Quality Project Analyst Lead (contract)
Healthcare Support/United Healthcare Optum
12.2022 - 05.2023
Data Analyst (contract)
Diskriter Inc./Almeda Health System
12.2021 - 04.2022
HEDIS Abstractor (contract)
Randstad Healthcare/United Healthcare
12.2020 - 05.2021
(contract) Louisiana Healthcare Network
Totalmed/Quality Improvement Coordinator
09.2019 - 03.2020
HEDIS Quality Improvement Abstractor (contract)
Lancesoft Staffing
11.2018 - 05.2019
HEDIS Clinical Quality Manager (contract)
Randstad Healthcare/United Healthcare
12.2015 - 05.2018
Operation Director/Part Time
C.S. King Preparatory Academy
08.2014 - Current
Medical Auditor, Revenue Analyst, Patient Account Representative
Our Lady of the Lake Regional Medical Center
04.2001 - 06.2015
Bachelor of Science - Psychology
University of Phoenix
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