RAUL A. RODRIGUEZ

• Assist A&G Management in auditing the AG department’s processes, AG Analysts, AG Data Entry process.
• Report monthly to AG management audit results by employee and overall, including but not limited to status, and findings.
• Identify areas of opportunity, develop and offer training.
• Assist the Manager in coordinating company or department trainings.
• Prepare weekly, quarterly, semi-annual, and any other special reports to management.
• Research, interpret, and enforce various sources of regulatory documentation including CMS Manuals, CFRs, IRE Manuals, and any other applicable policy.
• Audit Grievances and Appeals for part D redeterminations and part C reconsideration's meeting the Centers for Medicare & Medicaid Audit protocol standards.
• Assist in performing analysis of current situations and recommend priorities and goals for future needs.
• Identify access to care, service, medications, coding, provider, and billings risk areas, conduct focused reviews, and help in the implementation of corrective action as needed.
• Assist with completing AG Data Entry and AG Analyst functions.
• Verify accuracy of appeal data timeliness, processing, disposition and use of correct decision letters.
• Prepare case file for internal audits performed by other departments.
• Assist the Manager in the implementation of the AG annual audit and training Plan.
• Develop, and implement trainings as needed in the company or department.
• Conduct focused appeals and grievances training to new employees and dependent upon identified needs for departments and individuals.
• Orient internal and external customers on appeals and grievances issues based on established policies and procedures and his/her judgment.
• Schedule and conduct audits of the department and other internal departments according to CMS, and AAAHC standards and company policies and procedures.
• Ensure compliance with established internal control procedures by examining records, reports, operating practices, and documentation.
• Supported leadership by participating in team meetings and workshops to identify process improvements and quality measures in our Department.

• Responsible for auditing contracted vendors, to assure compliance with CMS standards and company’s policies and procedures.
• Maintain track of Compliance of our vendors according to the compliance program.
• Audit Annually our delegated entities functions and Financial statements mitigating legal and financial risks.
• Schedule and perform on-site or Off-site audits to determine the entities are following CMS standards and regulations.
• Ensure that revisions to policies and procedures are updated and revised yearly by the vendors compliance Department.
• Assist Manager with development, implementation, and maintenance of the Delegation Oversight Program and Annual workplan.
• Develop corrective action plans and analyze Internal performance measures.
• Design program and strategies through communication, education that can help the vendors comply with regulatory standards from CMS and the contractual agreement.
• Including strategies to maximize their resources and quality outcomes.
• Ensure Policies and Procedures are updated according to the regulation standards for NCQA and CMS.
• Prepare weekly, quarterly, semi-annual, Annual, and special reports to management.
• Research and interpretate various sources of regulatory documentation.
• Perform analysis of current vendor situations and recommend corrective action plans.
• Identify risk areas on the delegated functions such as claims, Utilization Management, credentialing, Model of Care program for HRA, Smoking Cessation, Call Center and implement corrective action as needed.
• Review of Addendums and contractual agreement of the vendor with the plan.
• Realize monthly spot checks of vendor employees and provider Network through the Office of Inspector General (OIG) and System for Award Management (SAM) Develop audit tools according to the applicable state and federal requirements.
• Monitor delegated activities to ensure compliance with company policy, CMS, NCQA, ASES, state and federal requirements including tracking receipt of data and reports per contractual obligations.
• Serve as a principal point of contact and liaison with delegates.
• Prepare materials for the Delegation Oversight Committee’s review which is composed of Senior Management and Compliance Oversight committee and Board of Directors.
• Perform pre-delegation audits and asses the proposed delegated entity capacity to manage and perform the delegated functions in accordance to state and federal laws.
• Audit the vendors financial solvency, program descriptions, tool, P&P, SOP and systems used to perform the delegated functions.
• Prepare audit report of Oversight activities for the vendor and present to the Delegation Oversight Committee.
• Participate and lead in special projects and duties as assigned.

• Work on Grievance and Appeals request from Member’s, Appointed representatives (AOR), Third parties representing the member.
• Review of clinical and non-clinical cases, quality of care issues for standard and expedite cases.
• Present the case investigation to our Chief Medical Officer for his/her decision.
• Work as a liaison between the Medical Management, Internal departments such as claims, legal counselor, provider network operations and compliance.
• Work with Complaint tracking module (CTM) cases received through HPMS module.
• Use of guidelines and tools from the Organization Determination Appeals & Grievances previous chapters 13 and 18 from Medicare.
• Follow URAC and NCQA standards Sending appropriate notices to members and providers within established time frames according to Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance.
• Analyze appeal request with Medical records, CMS regulations, Local and National Coverage Determinations and Milliman guidelines for pre and post service appeals.
• Interdepartmental communication with our Members service, Provider Network and contracting teams when the plan needs to educate our Network providers, vendors and internal or external staff.
• Manage daily mailing and printing operations for all notices sent.
• Monitor reports received three times a day by mailing vendor to ensure notices were sent timely.
• Present appeals to our Chief Medical Officer (CMO) for his determination to overturn or upheld a case.
• Send claims for reprocessing to our claims Department and Marketing or FWA investigations to our compliance Department.

Monitor billing and claims processes, Follow up with Medical Billing
issues or concerns. Conduct ongoing training of Medical Billing and
Collection Analysts on billing and coding criteria and best practices.
Review chart notes and facilitate appeals and/or provide oversight of
Medical Billing and Collection Analysts claim appeals. Keep up to
date on payor changes and inform staff as needed.

Ensure correct procedures code, modifier use and sequencing
to provide accuracy and completeness of clinical documentation and allowable physician reimbursement under the federal CMS reporting guidelines as well as all other third-party payors.

Serve as trainer for Medical Billing staff. Supervise Medical Billing and
Collection Analysts including efficiency and effectiveness of job
performance, areas for process improvements, conducting performance evaluations and participation in hiring decisions.

Ensure adherence to compliance program and company policies and
procedures Perform all other duties as assigned; complete tasks and
projects by deadlines established by the Director.

Supervise Medical Billing and Collection Analysts including efficiency and effectiveness of job performance, areas for process improvements, conducting performance evaluations and participation in hiring decisions.

Provide information and orientation to the providers about credentialing and re-credentialing process, contracting status, claims status, among other information.

Educates the providers about correct billing, claims submission, covered benefits, among others.

Attend provider’s complaints and referrals of internal and external clients.

Quality audits to new hires, hearing inbound/outbound calls recordings and provide feedback.

Issue resolution coordinator resolving cases presented by the network providers regarding their payments in advance, denials for billing and coding and financial recovery in process for their encounters.