PETER VALDEZ

• Working as a Contract Program Auditor allows me to conduct contract monitoring work that includes annual administrative and programmatic monitoring during each fiscal year.
• My job experience has me conducting program evaluation audits of SUD/Prevention/DUI/OTP (Opioid Treatment Programs) providers to ensure contract compliance is achieved.

Programmatic Monitoring Review duties include: Compile all relevant information that includes organizational and administrative documents that includes patient treatment related information.

• Duties include running data reports from My Avatar and from the Provider Connect to monitor my assigned agencies.
• My duties allow me to analyze the compiled documents to ensure compliance and to identify the area of improvement.
• Conduct Billing review to ensure compliance by pulling the billing charges and verifying group sign in sheets and/or the individual counseling sessions.
• Conduct patient chart review to ensure charts have the required documents.
• Conduct facility/site inspections by going on-site or virtual (due to Covid19).
• Help process Funding Augmentations for the providers who are requesting additional funding.
• Conduct the Entrance and Exit conferences during the provider's audit.
• Corrective Action Plan (CAP) duties allows me to collaborate with the provider to develop the CAP.
• Credentialing duties: Compile and review the provider's licenses/certifications and other program requirements such as: DMC certification, ASAM designation and the Insurance requirements that all providers must have.
• Complaints and Grievance: duties include, contacting the individual submitting the complaint to gain full understanding.
• Conduct review and analysis, conduct interviews.
• DHCS state audit experience: Review the monitoring report to become familiar with the "findings" or "issues" cited.
• Collaborate with the provider to develop the Corrective Action Plan (CAP).
• This includes both Postservice-Postpayment Reviews (PSPP) and programmatic audits.
• LAC Auditor-Controller Audits (A-C) experience, allows me to review the monitoring report to become familiar with the "findings" cited.
• Substance Abuse Service Helpline (SASH) experience, my duties enable me to follow-up on issues identified by SASH with the provider to ensure issues are resolved.
• Service Bed Availability Tool (SBAT) Monitoring experience.
• My duties include monitoring of the SBAT to confirm the information listed is accurate and consistent with our contracted providers.
• It also enables me to work with the provider to help resolve any issues identified.
• My duties as a CPA allow me to analyze and evaluate and to make any recommendations to the provider to ensure the clients get their services and to make sure the provider is in compliance with DHCS and with LA County guidelines.
• Other essential job functions: Assist our Community Based Providers with the development, implementation of newly added programs, such as: adding Residential sites or adding Outpatient or Intensive Outpatient sites, my duties enable me to provide some guidance on State regulations and County policies and procedures.
• My experience allows me to interpret Federal, State, and County legislative regulations and mandates that allows me to help our providers in need.
• This working experience enables me to have an effective working relationship with staff and our contracted community- based providers.
• Improved program efficiency by conducting comprehensive audits and identifying areas for improvement.
• Streamlined internal processes for increased productivity by implementing effective audit recommendations.
• Optimized resource allocation, evaluating programs'' effectiveness in meeting strategic goals and objectives.

• Link families in need to mental health services.
• Work with homeless families and link them to our contracted homeless providers throughout LA County.
• Advise and consult with family members on our established mental health services that our program offers.
• Conduct interviews with family members or authorized members to investigate complaints by the reporting party.
• Prepare recommendations by summarizing results after my investigation of non-compliance by our providers.
• Working in this program allows me to monitor and evaluate our contracted providers to ensure they are providing direct service or social programs to our foster kids.
• My work allows me to identify possible areas of non-compliance with contractual terms and to provide consultative services to our providers regarding their deficiencies.
• Collaborate with DCFS, School districts, Probation, and other Mental Health providers and Community Based organizations to coordinate placement and mental health services.
• Monitor our substance abuse providers for contractual and program compliance.
• Assist in the completion of program reporting requirements, progress reports and monitoring of assigned cases to make sure providers are in compliance.
• Consistently met deadlines under pressure while maintaining high-quality work output in a fast-paced environment.
• Established strong working relationships with clients through excellent communication skills, fostering long-term partnerships built on trust.

• Coordinate mental health services to our Adult clients by providing inpatient psychiatric placement by working as an IMD Liaison.
• Provide coordination, linkage, and integration of inpatient and residential placement throughout the system to reduce rates of re-hospitalization, incarceration, and the need for long-term institutional care.
• My work here allowed me to deliver mental health services in our contracted inpatient facilities.
• Our program also provides placement for clients that are dual-diagnosed with substance abuse, and clients who may be homeless.
• Provide administrative staff capacity functions by analyzing and advising our line manager by providing program and administrative support, and make recommendations for the solutions of problems of our program.
• Assist management by performing research and making recommendations on use of personnel and workflow fluctuations of our program to accomplish our department’s objectives.
• Assist in the completion of program reporting requirements, including implementation of progress reports, expenditure reports, quality assessment and monitoring of our IMD program .Work with all County Hospitals (Harbor UCLA, Olive View MC, LAC USC Augustus Hawkins, LAC-USC MC) by placing adult clients into inpatient psychiatric settings (which include our IMD’s, IMD Step Down, Sub-Acute, and State Hospital level of care).
• Work with Twin Towers and Metropolitan State Hospital for placement of their forensic clients into our contracted facilities.
• Act as a liaison between other County Departments and collaborate with community based organizations to promote the health care needs of Los Angeles County residents.
• I perform basic to routine analytical assignments that involve researching, analyzing and synthesizing data that enable me to recommend solutions to problems related to program support.
• My work allowed me to conduct program evaluation inside our IMD facilities to ensure that appropriate quality of care is maintained by our contracted providers (I did this work for two years before working in my administrative role here at CRM).
• Discuss Non-Compliance issues that arise during case conference meetings and come up with resolutions.

I also provided housing retention services and linkage.

• My work also enabled me to evaluate our programs in our IMD and IMD Step-down facilities (psychiatric inpatient facilities).
• My responsible staff experience here in this program allowed me to gain valuable journey-level knowledge of rules, regulations and guidelines relating to this program.

• Duties include interpretation of Managed Care contracts, Medicare and Medicaid rules and regulations to ensure proper and timely reimbursement collection.
• Review remittances advice for payment accuracy and or contractual adjustments as needed.
• Routinely meet or exceed individual monthly collection goals; consistent reduction of aging days on assigned accounts.
• Analyze and study accounts to make sure we are in Compliance with State and Federal guidelines along with strong evaluation and claim negotiation skills.
• Investigate denied claims and Interpret complex contract language to maximize reimbursement for high dollar hospital claims.
• Managed and monitored various insurance contracts to ensure reimbursement compliance was maintained, this would enable me to ensure both accuracy and compliance on their part.
• My work would allow me to audit reimbursements invoices to ensure contractual compliance.
• Bill and edit Medicare/Medi-Cal accounts, use Medicare Manager and Cirius Billing software.
• Knowledge of all inpatient and outpatient specialized billing (TCU, SSO, RO, Rehab).
• Prepare reimbursement claims for health care provided under Federal, State, and special medical aid programs.
• Help prepare Medicare and Commercial cost reports by gathering monthly data to complete the mandated reports.
• Demonstrated ability to accurately analyze information and make sound decisions, and inform management of problems and recommend corrective action.
• Claims adjuster experience in investigating, evaluating, negotiating and settling claims with respect to coverage, liability.
• Work on denied claims and resolve the “coding” error if applicable.
• Insurance consumer Advocacy experience working on Consumer issues, complaints or Insurance Compliance matters.
• Identify and investigate denied claims, mediate resolution of patient (consumer) complaints and interact with the Insurance Company of our patient to resolve both individual and general issues, complaints and any violation in health insurance laws.