Lorilee Rotert

• Drive strategy, formulate action plans and priorities to improve Quality and Risk adjustment outcomes. Share market comparison data and analysis with Health Care Partners and Executives.
• Innovation, program design and implementation to improve quality through process improvement in appropriateness and effectiveness.
• Manage provider networks that support client base.
• Utilize data to identify key performance indicators with health group partners to provide roadmap for transformation/success in patient care outcomes, patient experience, and other business goals.
• HCC reviews, comparison data and share education with provider group partners.
• Oversee network analysis and implementation for medical groups.
• Currently operating as SME, available to assist training team onboarding new hires, and Mentor to new hires and peers.
• Develop materials for presentation to health system administration and leadership, to present strategy and recommendations for improvement opportunities for STARS HEDIS measures and Risk.
• Participated on leadership subcommittee meetings to improve efficiency of reporting, create OneNote by role, assist with share point site clean-up, and command center dashboard.
• Optum Insight Elevate Leadership Program and Emerging Leaders Program Alumni
• Optum Integrated Field Ops Approved Trainer - February 2022 to present.
• Present coding presentations for attendees to earn CEU/CME credit.
• Peer to peer SME presenting or co-hosting on Optum national coding forum.
• Review of Optum presentations and resource materials for revision and updating as needed.
• Current Growth Initiatives:
• Project Management Course / Maxwell Leadership Growth Plan 2025 / AI - Copilot

Leading Provider Education Team for Illinois, Montana, New Mexico, Oklahoma and Texas, drive risk adjustment strategy, education and outreach efforts with contracted medical groups and individual providers in Illinois, Montana, New Mexico, Oklahoma, and Texas. Worked in tandem with Quality team for Medicare Advantage and Dual covered/DSNP members.

• Created, developed tools and presentations for risk adjustment strategy.
• Data, and metrics for presentation at JOC meetings with executives and leadership for medium and large health systems.
• Worked to build provider education team, implemented strategy and transformation resulting in highest level of provider engagement since initial implementation of provider education team (five years prior).
• Developed training and educational materials, development of policies and procedures and internal coding guidelines.
• Second level review RADV and other HCC validation suspect reviews.
• Collaboration with internal data team to identify and provide meaningful data to support medical group efforts.
• Developed presentations for provider education team to utilize with provider groups.
• Worked in collaboration with Network and Clinical staff to achieve departmental/regional/corporate goals, develop and maintain relationships with key stakeholders within provider groups and health systems.
• Implemented Team Roadmap and strategy, training, coaching, and providing applicable feedback to team members
• Worked with vendors and providers on special projects. Data assessment, clinic visits, presenting education and chart review audit findings.

• Performed clinical, billing, coding, and cost setting reviews, pre and post payment utilizing medical, contractual, legislative, policy and other information to validate claims submitted and billed for all lines of business.
• Conducted research, preparing documentation of findings and consulting with Medical Director. Coordination with all departments involved in each case required, including Customer Service, PASS (Provider Access and Servicing Strategy), Network Management, Marketing, Case Management, Medical Review, Legal, Pricing and Database.

• Provider education and risk adjustment strategy implementation, working with provider groups to assist in improving diagnosis coding accuracy, RAF scores, knowledge of appropriate claims coding and documentation for Medicare and Dual coverage/DSNP members.
• Closed suspect second level reviews.
• Utilized data analytics for assessment of medical groups, health systems and individual provider performance for provider education.
• Collaborated with network, medical directors, clinical staff to achieve mutual goals in working with provider groups.
• Created, developed tools and presentations to share risk adjustment data and metrics to executives at JOC meetings with large health systems.
• Researched and analyzed medical records, utilizing claim systems to verify and assess claims and documentation accuracy.
• Assisted Network team, and clinical team in presenting and sharing data in JOC meetings.
• Working with vendors, and distribution of incentive payments to provider groups.

• Quality/HEDIS/Stars/Embedded in Clinic.
• Worked to meet divisional goals, assisted and shared resources with providers, HEDIS gap closure, quality of care initiatives and improving star ratings.
• Chart review/audit for quality measures, identifying & assisting with closing patient care gaps.
• Collaboration and Monthly Touchpoints with medical groups, HEDIS project, working in partnership with medical groups on targeted initiatives and health fair events to close care gaps, and working onsite with specific medical groups, interacting with providers on a routine basis.
• STAR collaboration meetings with Medicare Advantage Medical Directors, Provider Relations, and other stakeholders.

• Responsibilities included, resolution & follow up of claim denials, claim coding, corrections, research, and the appeal process. Medical billing, provider contracting, credentialing & enrollment, audits, EDI issues, and assisted providers with EHR attestation process. Written and verbal interaction with physician clients, insurance representatives, and patients. Worked to create employee training resources and obtaining resources related to coding changes, CMS updates, guidelines and other applicable resources.

• Processing, adjudication, and correcting Medicaid medical and facility claims for the state of New Mexico.

• Processing, adjudication, and correcting commer medical and facility claims.

• Worked as a liaison between marketing and claims, assisting with resolution of claim related issues. Facility and medical claim corrections to resolve issues identified by Large Group Marketing Representatives. Also provided support in Medicaid customer service

• Provided customer service to members and providers on benefits, claims and other issues related to medical insurance policies.
• Led and coordinated program for “Away from Home Care” for HMO (managed care) members while traveling, or temporarily living out of state.
• Project Management for process improvement and implementation for the Away from Home Care program, from a manual claim, enrollment, authorization process to an automated process.
• Responsible for training teams on administration of the HMO Away from Home Care program.

• Responsibilities included processing & adjudication of medical claims for Blue Lincs HMO (managed care) members.