Mfon Usiere

Medicare Advantage risk adjustment leader with extensive and progressive years of experience across academic medical centers, federal healthcare systems, national health plans, and independent consulting. Proven ability to operate effectively on both the provider and payer side of the risk adjustment equation from clinical documentation at the point of care (UMMC, MedStar, VA) to enterprise RA program management (UnitedHealth/Optum, Cigna, Denver Health Medical Plan). Deep expertise in CMS-HCC methodology, prospective and retrospective coding programs, RADV audit readiness, market-level KPI governance, and translating risk adjustment performance data into executive-level strategy.

Currently applying same full-spectrum background as a principal consultant through Elite Medical Consulting, LLC.

Principal Consultant — Medicare Risk Adjustment at Elite Medical Consulting, LLC (2025-10 – Present)

Provide independent risk adjustment consulting to Medicare Advantage health plans, physician organizations, and ACOs — spanning program design, RADV readiness, provider education, and market performance strategy.

• Conduct RA program assessments evaluating current-state coding capture, encounter data submission quality, vendor performance, and CMS compliance posture; deliver prioritized improvement roadmaps.
• Design and facilitate provider education programs on CMS-HCC documentation specificity, ICD-10-CM coding guidelines, and prospective HCC closure workflows tailored to each client's EHR environment.
• Support executive reporting by building KPI dashboards and market-level RA performance packages for client leadership teams, including risk score trending, RAF variance analysis, and audit readiness scorecards.
• Provide advisory on regulatory developments including CMS V28 model transition, RADV final rule implications, and encounter data submission best practices under RAPS and EDPS.

Medicare Risk Adjustment Market Manager at Denver Health Medical Plan (2024-09 – 2025-09)

Served as the market-level RA lead for Denver Health's Medicare Advantage product, managing all aspects of risk adjustment program execution, provider engagement, and regulatory compliance.

• Led prospective and retrospective HCC programs in partnership with primary care, specialty, and value-based care teams — coordinating medical record retrieval, coding review, and encounter data resubmission workflows.
• Developed and maintained market RA dashboards tracking RAF score trends, HCC capture rates, coding acceptance rates, and RADV audit readiness status; presented findings to senior leadership monthly.
• Managed relationships with coding and medical record vendors, holding vendors accountable to SLAs for chart retrieval turnaround, coding accuracy, and encounter submission quality.
• Ensured compliance with CMS RA requirements including timely RAPS/EDPS submissions, V28 transition planning, and internal audit preparation aligned to RADV standards.
• Collaborated cross-functionally with Finance, Compliance, Network, and Clinical Quality teams to align RA activities with revenue integrity and Stars performance objectives.

Medicare Risk Adjustment Program Manager at Cigna Healthcare Insurance (2019-06 – 2024-09)

Managed Medicare Advantage risk adjustment programs across multiple regional markets, overseeing prospective HCC initiatives, retrospective chart review operations, and provider engagement strategy for a multi-state MA membership base.

• Served as market liaison between national RA strategy and local market execution — translating enterprise risk adjustment priorities into market-level action plans, workflows, and provider-facing programs.
• Built and maintained executive reporting infrastructure: monthly RA scorecards, quarterly business reviews, and annual CMS submission performance summaries delivered to VP and C-suite stakeholders.
• Led RADV audit preparedness cycles including internal mock audits, medical record documentation gap analyses, provider education on audit-ready documentation, and corrective action plan development.
• Oversaw encounter data submission quality assurance, partnering with IT and vendor teams to identify RAPS/EDPS rejection patterns and implement systematic remediation workflows.
• Directed provider outreach programs for HCC documentation improvement, coding specificity education, and annual wellness visit (AWV) / chronic condition recapture initiatives across contracted networks.
• Monitored CMS regulatory guidance and policy changes; led internal impact assessments and updated operational procedures accordingly to maintain compliance.

Risk Adjustment Consultant — Medicare Advantage at UnitedHealth Group (Optum) (2016-09 – 2018-06)

Provided risk adjustment consulting and program support to Medicare Advantage health plan clients and provider groups within the UHG/Optum ecosystem, focused on HCC coding accuracy, RAF optimization, and value-based care performance.

• Analyzed risk score data and generated market-level performance insights for client health plans, identifying coding gaps, undocumented chronic conditions, and encounter submission discrepancies.
• Supported prospective HCC programs including in-home assessments (IHA) coordination, annual wellness visit campaigns, and point-of-care HCC closure workflows in partnership with clinical teams.
• Delivered provider education and coding support on CMS-HCC documentation requirements, ICD-10-CM specificity, and value-based care coding obligations.
• Collaborated with encounter data and technology teams to improve RAPS/EDPS submission acceptance rates and resolve rejection patterns across client portfolios.

Health Information & Risk Adjustment Specialist at Veterans Affairs Medical Center (2014-07 – 2016-08)

Managed clinical coding and health information functions for the VA's Coatesville medical center, ensuring accurate and complete ICD-10-CM/PCS and CPT coding for all patient encounters across inpatient and outpatient settings.

• Applied CMS-HCC and risk adjustment coding principles to chronic disease documentation, gaining foundational expertise in the linkage between clinical documentation, diagnosis coding, and risk-based payment models.
• Collaborated with physicians and clinical staff on documentation improvement initiatives, ensuring diagnoses were captured at the highest level of specificity to support both quality reporting and appropriate reimbursement.
• Maintained compliance with federal health information regulations including HIPAA, VA coding guidelines, and CMS documentation standards.

Clinical Documentation & Coding Specialist at MedStar Franklin Square Medical Center (2012-02 – 2014-06)

Provided inpatient and outpatient clinical documentation improvement (CDI) and coding support within a large, acute-care community hospital affiliated with the MedStar Health system.

• Reviewed medical records for coding completeness and specificity, querying physicians on ambiguous or incomplete documentation to ensure accurate ICD-9/ICD-10 diagnosis and procedure coding.
• Supported DRG optimization and case mix index analysis, contributing to revenue integrity and accurate reimbursement for complex inpatient cases.
• Collaborated with HIM leadership on compliance audits, coding education sessions, and quality improvement initiatives.

Health Information Management Specialist at University of Maryland Medical Center (2006-07 – 2012-02)

Launched career in health information management at one of Maryland's premier academic medical centers, developing foundational expertise in medical coding (ICD-9, CPT), health record management, and clinical data integrity across a complex, multi-specialty teaching hospital environment.

• Applied coding and documentation standards across inpatient surgical, oncology, and complex chronic disease service lines — building the clinical documentation and diagnosis coding foundation that underpins risk adjustment expertise.
• Participated in coding quality audits, compliance reviews, and physician education programs on documentation specificity requirements.
• Gained early exposure to payer-provider dynamics, revenue cycle operations, and the intersection of clinical documentation and reimbursement policy.

Master of Public Administration (MPA) in Healthcare Management – University of Baltimore, School of Public and International Affairs (2014)

Bachelor of Science in Applied Chemistry / Pharmaceutics – University of Uyo, Nigeria (2004)