LISA MCDONOUGH
Jeffersonville
Summary
Professional with experience in leading delivery teams and driving project success. Proven track record of enhancing team collaboration and achieving significant results. Highly reliable and adaptable, skilled in project management and strategic planning.
Overview
30
30
years of professional experience
1
1
Certification
Work History
Program Delivery Lead
Humana
Louisville, KY
01.2023 - Current
- Lead and facilitate all CMS Risk Adjustment Data Validations (RADV) and OIG audits. This includes collaborating with other HQRI teams to ensure the work is managed and accomplished in accordance with our external audit obligations. Those collaborative teams include: HTA, Retrieval Ops, the Markets, and external vendors, ensuring proper data is obtained, provided to retrieval and the markets, as well as ultimate submission to the external regulatory agency and report out to upper management.
- Create and report out various workstream results to senior management, operations and market management.
- Facilitate meetings with management and staff to go over coding stats, trends and areas of opportunity.
- Responsible for facilitating and conducting special audits from Internal Audit, Legal or Compliance.
- Collaborate with internal and external legal counsel on risks, issues, and audits related to MRA.
- Identify process improvements to create efficiencies and streamline workstreams.
- Manage relationship and the related data request with our data analytics team.
- Serve as a SME on multiple projects and initiatives.
Quality, Audit & Compliance Associate Director
Humana
Louisville, KY
01.2008 - 12.2022
- Lead and facilitate all CMS Risk Adjustment Data Validations (RADV) and OIG audits. This includes working with HTA to provide claim details to the market; work with the markets on record retrieval and uploading to external vendor; partner with external vendor on workflow, record review and the delivery of universes; and ultimately provide stats to senior management.
- Responsible for the daily operations of the Medicare Risk Adjustment Audit team that is responsible for facilitating the Quarterly Coding Quality Audit, Quarterly Provider Data Validation Coder 2 Audit, In Home Wellness Assessment reviews. This includes managing certified medical coders and certified medical auditors.
- Provide results to senior management, operations and market management. Facilitate meetings with management and staff to go over coding stats, trends and areas of opportunity.
- Responsible for facilitating and conducting special audits from Internal Audit, Legal or Compliance.
- Collaborate with internal and external legal counsel on risks, issues, and audits related to MRA.
Manager of Operations, MRA
Humana
Louisville, KY
08.2005 - 01.2008
- Responsible for the daily operations of the Medicare Risk Adjustment unit that reviews medical records and processes claim modifications.
- Serve as a liaison between operational and functional areas, and identify and address barriers cross-functionally. Am accountable for managing inventory levels received from the markets and ensuring timely review and processing of request.
- Provide ongoing coaching and feedback to enhance associates contribution, competencies and performance. Responsible for a team of 30 associates that includes 2 supervisors.
Frontline Leader
Humana
Louisville, KY
09.2000 - 08.2005
- Led and guided associates in providing direct service to and for Humana customers. Managed a group of 12 associates.
- Represented Billing and Enrollment Service Center operations by active participation on process improvement and project teams (Corporate and Regional). Have defined processes for registration, verification, Customer Care Portal, web issue escalation and more.
- Responsible for leading a process transition effort from the Green Bay Service Center to the Louisville Service Center. Transition included the processing addition of 25 calls per day and 35 applications per day.
- Project Lead on the Customer Care Portal for the Billing and Enrollment Service Center. Average handle time reduced by 34 seconds during the first three months of release. This equates to $20,400,000 in savings annually.
- Responsible for hiring, coaching, leading and managing performance for the Service Center Units and the Web Enrollment Team.
- Developed communication plan for the Humana markets regarding call volume and updates for the eMainStreet Web Implementation. Managed the support required for each production turn which equates to over 360,000 calls annually.
- Responsible for managing to a service level of answering 80% of calls in 20 seconds or less.
Critical Inquiry Specialist
Humana
Louisville, KY
08.1996 - 09.2000
- Assisted in the resolution of Department of Insurance, Centers for Medicare and Medicaid Services and Congressional inquiries involving Medicare+Choice and Medigap policyholders.
- Responsible for the capitation recovery of over $15,000.00 annually through the account reconciliation process.
- Interacted with all of Medicare Operations and Service Centers, including Grievance and Appeals, Corporate Compliance, Customer Service and Executive Management on member issue resolution.
- Responsible for processing member, employer and provider inquiries and any additional information needed within a 24-hour timeframe.
- Assisted in training efforts for co-workers on claims processing and enrollment.
Education
Bachelor’s of Science - Business Management
Indiana University SE
New Albany, IN01.2021
Academic Diploma - undefined
Jeffersonville High School
Jeffersonville, IN01.1986
Skills
- Task delegation
- Scheduling coordination
- Stakeholder management
- Team Collaboration
- Issue resolution
- Cross-functional coordination
Accomplishments
Effectively built rapport with stakeholders, garnering their support and ensuring milestones are achieved.
Certification
- Certified Professional Coder, CPC, certification 5/2007
- Certified Professional Medical Auditor, CPMA, certification 7/2008
Timeline
Program Delivery Lead
Humana
01.2023 - Current
Quality, Audit & Compliance Associate Director
Humana
01.2008 - 12.2022
Manager of Operations, MRA
Humana
08.2005 - 01.2008
Frontline Leader
Humana
09.2000 - 08.2005
Critical Inquiry Specialist
Humana
08.1996 - 09.2000
Academic Diploma - undefined
Jeffersonville High School
Bachelor’s of Science - Business Management
Indiana University SE