Rita Hatfield
Baltimore,MD
Summary
Professional with robust experience in clinical review processes, prepared to drive results in healthcare evaluation. Skilled in assessing medical documentation, ensuring regulatory compliance, and providing accurate analysis. Strong focus on team collaboration and adaptability, consistently delivering reliable results. Known for effective communication, problem-solving, and maintaining high standards in dynamic environments.
Overview
16
16
years of professional experience
1
1
Certification
Work History
Clinical Reviewer
ATYELI – CAREFIRST
10.2023 - Current
- Support complex provider partners with HEDIS gaps in care, data feed, and remote medical record collection discussions and education for both the prospective project and hybrid project.
- Provide assistance with HEDIS onsite audits as required.
- Ensures that all HEDIS supplemental data sources are accurately represented and reported for comprehensive data completeness.
- Responsible for the completion and analysis of annual HEDIS results, in alignment with departmental goals.
- Possesses extensive knowledge of HEDIS, Medicare Stars, and Medicaid.
- Extensive experience in the collection and analysis of HEDIS measures and data spanning over 17 years.
- Performed extensive research and verified provider information.
- Initiated outbound calls to members in order to assist in scheduling appointments aimed at closing HEDIS gaps in care.
- Proficient in using multiple electronic medical records (EMRs) including Luminis, Athena, Epic, and TidalHealth.
- Conduct thorough testing and validation of claims and EMR data, ensuring alignment with HEDIS quality measures through reasonability checks.
- Ensured that all records abstracted and reviewed were completed with a 99% efficiency rating.
- During the perspective project, I was responsible for the WCV15 measure. By successfully achieving this measure, we attained our four-star rating.
HEDIS Case Management Processor
SAVIANCE – MOLINA
05.2023 - 10.2023
- Initiated outbound calls to members in order to assist in scheduling appointments aimed at closing HEDIS gaps in care.
- Conducted extensive research in QNXT for researching members and providers for accurate information to complete outreach.
- Ensured every call was recorded accurately in the clinical care system.
- Collaborated extensively with the provider partner to improve the partnership between the provider and Molina.
HEDIS Coordinator
TOTALMED - CENTENE
10.2022 - 05.2023
- Supported complex provider partners with HEDIS gaps in care, data feed, and remote medical record collection discussions and education.
- Proficient in using multiple electronic medical records (EMRs) to include Atena and Epic to retrieve patient medical records for Hedis project.
- Retrieved records from provider offices, reviewed all records, separated records for each patient, and uploaded them into the system for abstraction with a 100% accuracy.
- Collaborated extensively with the provider partner to improve the partnership between the provider and Centene.
- Responsible for the completion and analysis of annual HEDIS results, in alignment with departmental goals.
- Conduct thorough testing and validation of claims and EMR data, ensuring alignment with HEDIS quality measures through reasonability checks.
Physicians Recruiter
ANDROS
04.2022 - 10.2022
- Made follow-up calls to providers regarding Letters of Intent (LOI) for the Star-Plus Program on behalf of Aetna, Alignment, and Honest Health to help bridge gaps in credentialing providers with plans.
- Ensured that all Letters of Intent (LOIs) were sent to providers via fax and email after thoroughly reviewing the documents with the provider.
- Provided information and education to providers about all new Medicare and Medicare C plans.
- Documented all calls accurately into Glenridge Health web tracking, adhering to all company compliance policies.
HEDIS Abstractor
CSI Company for United Health Care
01.2022 - 04.2022
- Reviewed and abstracted both paper and electronic medical records in accordance with NCQA HEDIS Technical specifications to optimize Plan HEDIS scores, specializing in the abstraction of diabetic measures.
- Assisted in ensuring all gaps were closed within the HEDIS measurement year for diabetic measures.
- Medical records were abstracted with a proficiency rate of 99% accuracy into Ratelift.
- Working knowledge of HEDIS and Medicare Stars.
- Ensures that all HEDIS supplemental data sources are accurately represented and reported for comprehensive data completeness.
- Responsible for the completion and analysis of annual HEDIS results, in alignment with departmental goals.
HEDIS Abstractor
ASKING STAFF FOR AETNA BETTER HEALTH OF MARYLAND
01.2021 - 04.2021
- Reviewed and abstracted paper and electronic medical records utilizing NCQA HEDIS Technical specifications to optimize Plan HEDIS scores, assisting with closing all HEDIS measures for the measurement year.
- Contacted providers for medical records via phone or fax to acquire all medical records needed to ensure all Hedis measures would met compliance during medical record review (MMR).
- Collected medical records from provider offices and scanned them into QSHR for abstraction.
- Medical records were accurately abstracted into QHSR for HEDIS Audit with a 98% accuracy rate.
- Conducted thorough research on claims within QNXT to identify potential leads for obtaining medical records.
- Facilitates relationship with Medical Record Review (MRR) vendor for all technical aspects of annual MRR projects.
Health Insurance Agent
COLONIAL INSURANCE
07.2019 - 05.2020
- Contacted a list of prospective companies eligible for benefits through cold calling.
- Provided information and educated CEOs and Managers about Health Insurance Benefits.
- Provided education and assistance to each employee regarding customized health benefits to address gaps in care. This includes policies such as disability, critical illness, accidental and whole life insurance, as well as dental coverage.
- Fostered strong relationships with current clients and secured referrals to acquire new clientele.
- Provided assistance to individuals with lapsed policies and facilitated the reinstatement of their coverage.
HEDIS Coordinator
POPULUS GROUP FOR ANTHEM
03.2018 - 07.2019
- Contacted members and provided assistance in scheduling appointments for their specific HEDIS measures.
- Contacted healthcare providers and sent coordination of care letters via fax to ensure compliance with HEDIS measures.
- Performed comprehensive medical record reviews throughout the year, liaised with healthcare providers, obtained necessary medical documents, and organized patient charts.
AR Manager
NORTHERN PHARMACY AND RETAIL EQUIPMENT
07.2017 - 03.2018
- Supervised a department of six employees, addressing any concerns that arose and monitoring their productivity.
- Processed claims through CMS 1500 forms using Brightree.
- Specializing in the review and processing of all Blue Cross claims.
- Developed and managed price tables for medical equipment claims.
- Resolved multiple insurance denials, including those from Medicare and Medicaid. Established and maintained effective communication with insurance companies' provider relations departments to ensure prompt resolution of claims-related issues.
- Generated monthly accounts receivable and denial reports and assigned them to the appropriate staff member.
HEDIS Supervisor
MARYLAND PHYSICIANS CARE
06.2009 - 07.2017
- Managed a team of 10 staff members, consisting of 5 nurse consultants and 5 outreach staff.
- Reviewed and abstracted both paper and electronic medical records in accordance with NCQA HEDIS Technical Specifications to enhance Plan HEDIS scores.
- Ensured quality management of the Medical Record by adhering to all guidelines in HEDIS measures.
- Held monthly productivity meetings with staff and conducted individual 1:1 meeting, designing new organizational systems to enhance productivity.
- Completed desktop procedures for all assignments to ensure that everyone had clear instructions regarding their job duties.
- Conducted training sessions for staff on utilizing Outreach, the HEDIS Database, QXNT 51, Alchemy, and Immunet.
- All HIPAA and NCQA regulations were met and adhered to.
- Successfully maintained strong public relationships with providers, members, and local health departments.
- Developed a system for collecting immunizations, tracking all immunizations in the HEDIS database and spreadsheet, and contacting providers to obtain immunization records for uploading to the Supplemental Database.
- Collaborated with healthcare providers to ensure that members received care for preventive wellness visits.
- Oversaw the management of OMNI related to gift cards valued between $25,000 and $35,000 per month, ensuring 100% accuracy in the distribution to members.
- Organize a multi-day clinic that includes well-child check-ups, mammogram screenings, and cervical cancer clinics for the healthcare needs of members.
- Maintained and updated member information in QNXT and HEDIS systems and meticulously tracked all tasks on an Excel spreadsheet.
- Launched the Provider Liaison Program, improving procedure quality reviews and increasing member access to care and HEDIS scores.
Education
Associate of Arts - Chemical Dependency
Dundalk Community College
Baltimore Md05-1993
Skills
- Clinical judgment
- Patient confidentiality
- Clinical assessment
- Medical coding
- Teamwork and collaboration
- Critical thinking
- Organizational skills
- Electronic health records
- Microsoft Excel
- Records scanning
- Medical history recording
- Electronic health record applications
Certification
CBCS
Timeline
Clinical Reviewer
ATYELI – CAREFIRST
10.2023 - Current
HEDIS Case Management Processor
SAVIANCE – MOLINA
05.2023 - 10.2023
HEDIS Coordinator
TOTALMED - CENTENE
10.2022 - 05.2023
Physicians Recruiter
ANDROS
04.2022 - 10.2022
HEDIS Abstractor
CSI Company for United Health Care
01.2022 - 04.2022
HEDIS Abstractor
ASKING STAFF FOR AETNA BETTER HEALTH OF MARYLAND
01.2021 - 04.2021
Health Insurance Agent
COLONIAL INSURANCE
07.2019 - 05.2020
HEDIS Coordinator
POPULUS GROUP FOR ANTHEM
03.2018 - 07.2019
AR Manager
NORTHERN PHARMACY AND RETAIL EQUIPMENT
07.2017 - 03.2018
HEDIS Supervisor
MARYLAND PHYSICIANS CARE
06.2009 - 07.2017
Associate of Arts - Chemical Dependency
Dundalk Community College
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