Otisha Edmonson

• Conducted comprehensive operational and readiness reviews to ensure MCO contractual compliance, including data collection, trend analysis, and performance reporting.
• Monitored and ensured adherence to contract deliverables and regulatory standards to support program integrity and compliance.
• Analyzed issues and developed tailored recommendations, effectively communicating insights and proposed actions to senior management.
• Directed and implemented detailed planning and technical assistance initiatives to bolster operational efficiency and readiness across MCS division and managed care organizations.
• Coordinated efforts with stakeholders to evaluate and enhance program contracts and policies, driving efficiency and innovation.
• Oversaw operational on-site and desk reviews, enhancing the quality of technical information sessions and contractor material evaluations. Guided team members in executing quality assurance checks on staff reviews. Led efforts in report preparation to ensure clarity and accuracy.
• Established clear stakeholder communication protocols and developed operational timelines and guidelines to support team objectives.
• Led cross-divisional planning initiatives to enhance operational effectiveness and readiness of MCO operations. Oversaw staff training and assigned policy reviews to identify process improvement opportunities.
• Developed comprehensive management reports and responses to align project priorities with analytical insights and leadership guidance.
• Led the development and assessment of managed care contracts, RFPs, and evaluation tools to enhance program effectiveness. Oversaw comprehensive analysis of legislative changes and regulations impacting Medicaid and CHIP initiatives.
• Managed responses to legislative open record and audit requests within mandated timeframes.
• Cultivated strong relationships with agency personnel and external partners. Delivered timely responses to all inquiries and requests.
• Demonstrated proactive teamwork and commitment to enhancing customer service efficiency and accountability.
• Produced engaging PowerPoint presentations and comprehensive Visio timelines that facilitated project understanding. Enhanced team collaboration through clear visual documentation. Achieved improved stakeholder engagement by delivering high-quality presentation materials.
• Presented strategic insights and updates to agency staff and external stakeholders to enhance collaboration and understanding.
• Identified and communicated potential challenges to management, applying strategic judgment to determine appropriate actions.
• Achieved consistent staff development and high performance through effective leadership. Cultivated a collaborative environment that empowered team members to excel in their roles. Drove operational success by managing related duties efficiently.

• Ensured contract standards compliance and assessed MCO performance by systematically reviewing deliverables and evaluating adherence to state and federal regulations.
• Performed systematic evaluations of operational and contractual adherence, delivering critical insights and recommendations to health plan manager for informed decision-making.
• Fostered effective collaboration among health plan management staff, MCOS, and stakeholders to ensure development, monitoring, and updating of action plans for contractual compliance.
• Oversaw the assessment and resolution of contractual noncompliance issues. Partnered with HPM research and resolution teams to address escalated MCO challenges.
• Evaluated and processed legislative open records and audit requests, adhering to specified deadlines for efficient governance.
• Successfully facilitated operational on-sites and webinars, enhancing team collaboration. Streamlined desk reviews and implementation readiness processes, improving efficiency. Drove impactful information sessions and special research projects, delivering actionable insights.
• Designed and prepared detailed reports to summarize insights gained from readiness reviews.
• Cultivated strong partnerships with HHS staff and stakeholders to enhance collaboration. Delivered timely responses to inquiries and requests, fostering a supportive work environment.
• Ensured adherence to professional conduct standards to foster a positive work environment.
• Initiated and implemented strategies to enhance customer service efficiency and accountability in alignment with Medicaid/CHIP objectives.
• Assessed problematic situations and communicated resolutions to management, demonstrating sound judgment and initiative.
• Adhered to agency attendance policies and proactively undertook supplementary tasks to support team objectives.
• Assisted in developing and reviewing RFPs. Supported analysis of rules, bills, and state and federal laws affecting Medicaid and CHIP programs.

• Conducted comprehensive reviews of deliverables to guarantee compliance with contract standards and state and federal regulations, while evaluating MCO performance metrics.
• Conducted regular assessments of MCO compliance using established tools, facilitating timely communication of significant findings to Health Plan Manager with strategic recommendations.
• Led collaboration initiatives with health plan management staff, MCOs, and stakeholders to develop, monitor, and update action plans, ensuring contractual compliance.
• Led collaborative efforts to evaluate and implement solutions for contractual noncompliance. Coordinated with HPM research and resolution teams to address escalated MCO challenges.
• Facilitated timely responses to legislative open records and audit requests, maintaining adherence to established protocols.
• Facilitated successful operational on-site reviews and webinars, contributing to project readiness. Delivered comprehensive desk reviews and implementation assessments, leading to improved outcomes. Coordinated information sessions and special projects, enhancing team collaboration and effectiveness.
• Created informative materials and prepared detailed reports to summarize findings from readiness reviews and evaluations.
• Established clear communication channels with HHS staff and stakeholders to streamline response processes for requests and inquiries.
• Cultivated a professional environment characterized by minimal complaints, emphasizing teamwork and a commitment to superior customer service.
• Assessed and communicated potential issues to management, demonstrating sound judgment in decision-making processes.
• Assessed RFPs and conducted thorough evaluations of relevant legislation to enhance compliance and program effectiveness.
• Conducted engaging oral presentations to inform and educate agency staff and external stakeholders.
• Maintained consistent attendance and adherence to agency policies while demonstrating commitment to organizational goals through active project involvement.

• Conducted in-depth evaluations and continuous oversight of managed care organizations to ensure contract compliance and operational efficiency.
• Oversaw the administration of Medicaid and CHIP contracts, ensuring alignment with organizational policies and procedures. Collaborated with cross-functional teams to enhance care management strategies. Championed the development of best practices for contract compliance and procedural adherence.
• Analyzed MCO performance metrics and directed corrective measures to enhance operational efficiency.
• Conducted comprehensive reviews and analyses of MCO reporting to ensure accuracy and compliance.
• Assessed health plan management policies and provided recommendations for necessary policy and contract modifications.
• Assessed MCO contract deliverables and performance measures to ensure adherence to state and federal regulatory standards.
• Conducted regular assessments using standardized tools to ensure MCO operational and contractual effectiveness.
• Communicated significant MCO compliance and performance challenges to Health Plan Manager, offering strategic recommendations for resolution.
• Collaborated with management to identify and resolve issues swiftly, applying strategic decision-making to guide appropriate actions.
• Crafted and presented speeches to inform and inspire diverse audiences on relevant topics.
• Conducted thorough analysis of legislative changes to ensure compliance with Medicaid and CHIP regulations.

• Facilitated managed care enrollment for Medicaid-eligible individuals, supporting the Medicaid CHIP Division.
• Performed complex consultative and technical assistance to resolve managed care enrollment and data issues.
• Analyzed Managed Care data, including Medicaid/CHIP eligibility, premium payment, and encounter data, to identify and resolve discrepancies.
• Verified client eligibility using the Texas Integrated Eligibility Redesign System (TIERS) to ensure accurate service delivery.
• Collaborated with Operations Coordination staff to review data and recommend improvements, ensuring managed care data systems meet state and federal reporting requirements.
• Created ad-hoc reports and statistical analyses for management review and decision-making.
• Reviewed member cases to verify eligibility requirements and ensure accurate system classifications for premium payments.
• Provided timely, accurate responses to requests and inquiries from stakeholders and management.
• Communicated effectively, trained, and directed the work of team members.

Participated in workgroups, offering program expertise and technical information to support initiatives.

• Interpreted Medicaid policies and procedures while ensuring contract compliance.
• Supervised professional and technical staff; maintained effective communication and strong working relationships with managers, co-workers, agency personnel, stakeholders, and the public.
• Managed multiple and competing priorities in a fast-paced environment.
• Served as subject matter expert for Provider Claims Service, resolving complex nursing home and hospice service authorization cases.
• Clearly articulated case dispositions to providers and hotline staff; provided senior-level technical assistance to hotline team members.
• Conducted quality reviews and provided feedback to hotline staff to ensure high standards of service.
• Trained new and existing staff on correct policies and procedures for case processing and billing.
• Participated in agency workgroups focused on policy and procedure changes affecting service authorizations and payments.
• Researched and responded to issues raised by providers, recipients, and state or field staff.
• Reviewed and recommended updates to processing policies and procedures to improve effectiveness.
• Communicated complex policy and procedural information precisely in both verbal and written formats.
• Interacted daily with Medicaid providers, state program staff, regional staff, and third-party billing representatives to resolve payment issues and clarify required actions.
• Evaluated adherence to compliance, policies, and guidelines, and recommended changes to internal and external parties.
• Worked independently under limited supervision, exercising sound judgment.

• Advocated for clients to access Medicaid Managed Care Organization services while ensuring contract compliance.
• Addressed inquiries and resolved complaints related to Health and Human Services Commission agencies and programs, including Medicaid Managed Care, Medicaid/CHIP, Long-Term Care, and Medicaid Acute Care Services.
• Communicated effectively with organizations, stakeholders, and clients both orally and in writing to resolve issues and provide information.
• Maintained collaborative relationships with managers, co-workers, agency personnel, stakeholders, and the public.
• Conducted investigations: researched, gathered, and analyzed data to devise solutions for complex issues.
• Presented technical information clearly to a variety of audiences.
• Synthesized and summarized large volumes of data for internal and external reporting.
• Entered and tracked all inquiries and complaints to ensure accuracy and timely resolution.
• Monitored and ensured timely follow-up on cases referred to other departments or agencies.
• Performed advanced research and case review functions using Medicaid/CHIP eligibility and service authorization systems, including HEART, TIERS, SAVERR, and Phoenix.
• Reviewed case information from providers and state agencies; communicated with Managed Care Organizations and other agencies to resolve issues.
• Conducted follow-up activities to ensure resolution of cases; tracked and analyzed referrals to identify trends and recommend improvements.
• Analyzed documentation and evidence related to regulatory violations and summarized findings in technical reports.
• Prepared independent reviews and made determinations on disputed cases.
• Completed special projects utilizing Microsoft Word, Excel, and PowerPoint.
• Worked independently under limited supervision, exercising sound judgment.
• Maintained knowledge of state and federal regulatory processes and laws.
• Educated clients on Medicaid/CHIP eligibility and various managed care programs, including North STAR, STAR Health, STAR, and STAR+PLUS.