Mia Bell

Strategic healthcare executive with over a decade of leadership driving Risk Adjustment, Quality (STARS), and Compliance performance across Medicare Advantage, ACA, and Medicaid programs, known for building and scaling high-performing operations that optimize revenue integrity, strengthen regulatory alignment, and elevate clinical quality outcomes. Expert in end-to-end Risk Adjustment strategy, including coding accuracy, data integrity, provider engagement, and audit readiness, with a consistent track record of improving RAF performance and closing care gaps, while bringing strong leadership in vendor management, cross-functional collaboration, and enterprise governance to ensure operational efficiency and measurable financial impact.

• Member of the American Association of Professional Coders
• American Public Health Association
• Henry Kaiser Family Foundation

• Director, Market Engagement & Provider Performance, Risk Adjustment, ChenMed, Miami, FL, 10/01/23, 09/30/24, Designed and executed population health strategies to identify, engage, and manage high-risk members, improving risk score accuracy and care coordination., Led a team of Senior Program Managers specializing in Risk Adjustment, providing strategic direction and fostering a collaborative environment to enhance performance and expertise., Oversaw and analyzed Risk Adjustment reports across various markets, identifying trends and insights to inform strategic decisions and improve outcomes., Worked closely with contracted health plans to identify goals, barriers, and necessary data related to both Risk Adjustment and Quality Improvement initiatives, ensuring alignment with contractual obligations., Developed and implemented strategies in collaboration with market teams to achieve corporate outcomes and meet contractual requirements related to risk adjustment., Designed and delivered educational programs for providers to enhance understanding of risk adjustment processes, coding accuracy, and data requirements, fostering improved documentation practices., Led initiatives aimed at improving patient quality outcomes through enhanced risk adjustment processes, ensuring that clinical interventions are effectively documented and reported., Provided comprehensive clinical documentation and medical coding support for market teams, facilitating accurate data capture and compliance with regulatory standards., Utilized data analytics to drive strategic planning and operational improvements, enhancing the effectiveness of Risk Adjustment initiatives across the organization., Established and maintained effective communication channels with internal and external stakeholders, ensuring alignment of goals and expectations related to Risk Adjustment and Quality initiatives., Led efforts to identify and address performance gaps within risk adjustment processes, implementing targeted interventions to enhance quality and efficiency., Ensured adherence to contractual obligations and regulatory requirements, monitoring compliance and implementing corrective actions as needed to mitigate risks., Collaborated with market leaders to create tailored strategies that align with corporate objectives, enhancing the effectiveness of risk adjustment initiative.
• Senior Manager, Medicare Advantage & ACA Risk Adjustment Operations (Remote), Blue Cross-Blue Shield of Massachusetts, Boston, MA, 03/01/22, 10/31/23, Developed and implemented enterprise-wide Risk Adjustment strategies to optimize financial performance and ensure compliance with CMS and ACA regulations., Led end-to-end Risk Adjustment operations, including prospective, concurrent, and retrospective programs, ensuring accuracy in coding and data submissions., Spearheaded initiatives to enhance coding accuracy and documentation integrity, leading to improved risk score capture and optimized revenue reconciliation., Oversaw a coding team, audit team, medical records retrieval team, ensuring accurate coding and timely access to patient data, enhancing the overall quality of risk adjustment processes., Conducted comprehensive data analysis to identify risk patterns and trends, generating reports that informed decision-making and strategic planning for Medicare Advantage and ACA Risk projects., Led comprehensive Risk Adjustment Compliance programs, ensuring adherence to CMS and HHS regulatory requirements, and providing strategic oversight for Risk Adjustment Data Validation (RADV) audits., Developed and implemented internal Medical Coding Compliance policies, ensuring compliance with ICD-10, CPT, and HCPCS coding standards to meet federal, state, and payer requirements., Developed and delivered training programs for staff on risk adjustment processes, coding accuracy, and data integrity, enhancing overall project performance and compliance., Oversaw multiple risk adjustment projects concurrently, managing timelines, resources, and stakeholder expectations to achieve program goals., Established key performance indicators (KPIs) to measure the effectiveness of risk adjustment initiatives, using data-driven insights to inform continuous improvement efforts., Worked closely with cross-functional teams, including clinical, actuarial, and compliance departments, to develop programs for health plan population., Provided leadership audit readiness and response for CMS and HHS RADV audits, working closely with cross-functional teams to ensure preparedness and effective resolution of audit findings., Monitored Encounters and EDPS Risk Adjustment submission as well ensure submissions were submitted timely to submission vendors., Ensured continuous monitoring and improvement of compliance programs to mitigate audit risks and maintain regulatory standards.
• Supervisor, Medicare Advantage & ACA Risk Adjustment Operations, Blue Cross-Blue Shield of Louisiana, Baton Rouge, LA, 09/01/18, 03/31/22, Supervised coding team, audit team and medical records retrieval team, ensuring accurate coding and timely access to patient data, enhancing the overall quality of risk adjustment processes., Led retrospective, prospective, and concurrent risk adjustment projects, ensuring compliance with regulations and ensuring timely submission., Monitored Encounters and EDPS Risk Adjustment submission as well ensure submissions were submitted timely to submission vendors., Conducted comprehensive data analysis to identify risk patterns and trends, generating reports that informed decision-making and strategic planning for Medicare Advantage and ACA Risk projects., Monitored comprehensive Risk Adjustment Compliance programs, ensuring adherence to CMS and HHS regulatory requirements, and providing strategic oversight for Risk Adjustment Data Validation (RADV) audits., Developed and implemented internal Medical Coding Risk Adjustment Guidelines, ensuring compliance with ICD-10, CPT, and HCPCS coding standards to meet federal, state, and payer requirements., Developed and delivered training programs for staff on risk adjustment processes, coding accuracy, and data integrity, enhancing overall project performance and compliance., Oversaw multiple risk adjustment projects concurrently, managing timelines, resources, and stakeholder expectations to achieve program goals., Worked closely with cross-functional teams, including clinical, actuarial, and compliance departments, to develop programs for health plan population.
• Senior Outcomes Specialist, AmeriHealth Caritas of Louisiana, Baton Rouge, LA, 08/01/17, 09/30/18, Created a Hybrid 'In-House' process and year-round supplemental data collection process to improve state performance and accreditation measures., Assist in developing a tool to collect non-standard supplemental data., Manage Hybrid HEDIS project., Analyze member gaps (Risk & HEDIS) to implement quality improvement programs., Created interventions, programs, and member initiatives to improve quality outcomes and member experience., Facilitate the electronic exchange of clinical communication such as diagnosis, procedures, lab, and claims data from ACOs and health systems., Works with Provider Network & Value-based Team to facilitate gap closure and consults on efforts that may improve provider engagement., Responsible for reporting, analyzing, tracking, and trending HEDIS and CAHPS data., Responsible for assuring accuracy and validity of HEDIS and CAHPS data., Collaborate with customers at all levels of the organization to define objectives, suggest conclusions, and support decision making., Created interventions utilizing social determinants data and population health tools., Drill down analysis based on provider group rates based on HEDIS outcomes and member risk scores to determine where the plan can impact and improve provider performance., Lead a bi-weekly meeting with Outcome Specialist in other markets to teach them how to validate HEDIS data, and member risk scores and identify areas of opportunity for plan performance.
• HEDIS Manager, Anthem - Healthy Blue Louisiana, Baton Rouge, LA, 10/01/15, 08/31/17, Managed a team of 5 HEDIS Abstractors and 4 Medical Records Retrieval Specialists., Managed HEDIS Hybrid 'in-house' project and year-round supplemental data collection., Perform systematic and detailed review of encounters data to evaluate missed opportunities for HEDIS measures., Managed Louisiana Department of Health (LDH) Performance Improvement Projects; Prematurity and ADHD PIP., Prepared data and QM responses for EQRO Audit., Maintained HEDIS and CAHPS NCQA Workplans., Vendor oversight of Risk Adjustment projects; MRR and RA Coding., Vendor Oversight of CAHPS surveys., Developed strategy with multiple enterprise departments and external vendors to develop innovative databases and technology to improve quality outcomes., Monitor state contract requirements ensuring that the health plan was on track in meeting state performance HEDIS measures, EPSDT, and CAHPS targets., Identified, and developed processes procedures, and operations for performance management to improve outcomes., Coordinated, implemented, and executed quality improvement projects, ensuring consistency with company strategy, commitments, and AOP goals., Developed and implemented initiatives to strategically improve project processes., Worked with corporate enterprises and the local health plan to develop CMS AMP incentive models and value base incentive programs., Served as health plan subject matter expert in HEDIS and Risk Adjustment Medical Coding.
• HEDIS Coordinator / Internal Provider Relations Specialist, Centene Louisiana Healthcare Connections, Baton Rouge, LA, 04/01/13, 10/31/15, Managed HEDIS Call Center, Abstractors, and Medical Records Specialist., Implemented and managed HEDIS hybrid 'in-house' project., Risk Adjustment Project vendor oversight; MRR and RA coding., Managed 'High Risk' member programs., Developed and managed HEDIS & CAHPS NCQA workplan., CAHPS vendor oversight., Developed Interventions to improve HEDIS, CAHPS, and EPSDT rates., Synthesized performance data, and prepared presentation materials. presented comparative complex reports to local, state, and enterprise quality committees., Performed duties such as rate investigation and auditing to validate the accuracy of HEDIS data., Evaluated and monitored performance and efficiency of programs to ensure that implementations meet targeted timelines., Worked with local health plans and enterprises to create strategies to meet Louisiana Department of Health and Hospitals (LDH) performance HEDIS measure target., Worked with the LDH contracted consultants IPRO to create interventions and process measures for Louisiana Department of Health and Hospitals (LDH) PIP to improve prematurity outcomes in Louisiana., Investigate and provide resolved complex claims and provide resolutions to healthcare systems., High visibility into reprocessing of claims attributed to CPT, ICD, Medicaid Fee-Schedule, and contractual agreements., Configured claims system to process claims according to member benefits, Medicaid fee schedule, NCCI edits, MUE billing rules, and contractual agreements., Perform system configuration, mapping, and claims management for EDI base transactions and process., Monitor and test EDI transactions in Amisys to ensure accurate claims processing., Tracked, trend and analyzed claims rejections and provided training with in-network providers to avoid unnecessary claims denials., Worked with claims recovery team and SIU to identify provider upcoding and unbundling., Trained provider relations and claims department on correct coding and billing procedures., Draft provider resource materials such as fax blast, provider newsletters, and provider billing manual., Lead ICD-10 implementation for the health plan., Coding & Claims SME.
• Healthcare Consultant, Edelberg Compliance Associates, Baton Rouge, LA, 04/01/12, 04/30/13, Directed and mentored a team of coding, auditing, and billing staff, fostering a culture of continuous improvement and collaboration., Ensured timely delivery of client projects by effectively managing project timelines and resources, resulting in a 95% on-time completion rate., Conducted quality assurance reviews on coding accuracy and compliance, reducing discrepancies by 30% through rigorous auditing processes., Built and maintained strong relationships with allocated clients, proactively addressing their needs and enhancing client satisfaction., Collaborated with sales and product teams to identify upsell opportunities, leading to a 20% increase in additional sales for assigned clients., Provided travel consultation services, ensuring compliance and smooth logistics for client projects.