Delegation Management Specialist I - Dignity Health Management Services Organization (DHMSO) (CommonSpirit Health) - Bakersfield, CA - remote
(2022-02 - 2026-06)
- CAPs/RCAs: Assisted in preparing CAPs and RCAs.
- Prepared file builds as needed for submission to Health Plans.
- Sent out Audit notices to the functional departments to complete CAPs & RCAs.
- Project Management for UM Work Plans.
- Created Work Plan Calendar with Links to individual Work Plans.
- Submitted final Work Plan to respective Health Plan and log submission dates.
- Prepared Monthly ODAG Reports and submitted to Health Plans.
- Attended Health Plan Audits.
- Coordinated daily, weekly, monthly tasks and updated trackers to meet deadlines and regulatory compliance.
- Created and presented Compliance PowerPoint Meeting presentations at Delegation Management & UM Committee Meetings.
- Uploaded data and reports to portals.
- Maintained adherence to all regulatory compliance requirements.
- Appeals & Grievances Department – processed Appeals & Grievances cases as needed.
QI Coordinator - Desert Oasis Healthcare (DOHC)
(1999-03 - 2021-08)
Coordinate and collaborate with QI Director and the QI team in ensuring all aspects of the Department's functions are met. Maintain necessary logs, tracking, prepare Minutes, Agendas, producing reports, policies and procedures, Manuals, composing letters, merging files, uploading portals, emailing requested documents, provide proof of all submissions, adhere to HIPAA regulations and confidentiality at all times. Compose letters and maintain file systems.
Collaborate with all levels of management. Update matrixes, grids, and problem-solve computer glitches with IT. Assist with any Administrative functions in the department. Assist in putting together confidential cases for Risk Management.
- HEDIS Management: Served as the Project Manager and coordinated all aspects of HEDIS Collection.
- Worked with QI Nurses to have all completed HEDIS submission requests completed timely and submitted to the Health Plans.
- Organize HEDIS records and maintain database for easy accessibility. Serve as the Project Manager for HEDIS. Review HEDIS Measures annually and update coversheets as necessary per updated current HEDIS year Measurement to ensure HEDIS Measures are met; for example: Care for Older Adults (COA), Medication Reconciliation (MR), Colorectal CA Screening (CCS), etc.
- Schedule regular meetings for workflow progress to ensure completion of all HEDIS Measure Requests.
- Retrieve records from the database to answer questions if needed. Merge files, scan all records and save to database.
- Track every record and identify pursuits by measure and sort lists as needed. Ensure coversheet is completed by measure before submission.
- Review GAP lists with QI Nurses.
- Prepare HEDIS billing invoices following HEDIS Project completion.
- File Database Management: Maintain electronic files in an organized fashion and assist staff with easy quick retrieval. Perform file merges and upload files, policies, reports, data to various portals. Attempt to problem-solve issues or request IT assistance if needed.
- Grievances Coordination: Process Grievances intake, prepare provider query letters, and send cases out for MDR and/or leveling. Send out response to the Health Plan. Assist with Appeals cases if needed. Present training material to Compliance Department.
- Assist with preparing Work Plans.
- Policies and Procedure Manuals: Served as Project Manager and maintained and updated all company Standard Operating Procedures Manual(s). HIPAA, UM, Quality Assurance, Living & Aging Well, Disease Management, Coordination of Care, Case Management, Intense Case Management, PHI, Clinic Operations, Department-specific, Medical Records, Clinical Practice Guidelines. Worked with Providers to create Clinical Practice Guidelines. Created and wrote policies and work with Senior Management and/or managem
- Provider Orientation: Coordination of Provider Orientation. Prepare Policy Manuals as needed. Prepare Agendas and Training materials, presentation setup.
- Conduct Appointment Access surveys with PCP & SCP Provider offices.
- Prepare and send out PCP & SCP Provider Satisfaction Surveys and record results.
- Continuity of Care – Prepare Continuity of Care letters.
- Prepare Potential Quality of Care Issues (PQI & Risk Management: Complete forms, cases, letters, and entries into database. Send out query letters as needed.
- Attend Quality Improvement Council and Utilization Management Committee Meetings prepare Agenda, and record Minutes.
