Tyneca Jefferson
Sr Specialist, Quality Intervention/QI Compliance at MOLINA HEALTHCARE INC- Claim this Profile
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Topline Score
Bio
Credentials
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Communicating about Culturally Sensitive Issues
LinkedInFeb, 2021- Nov, 2024 -
Project Management Foundations
LinkedInFeb, 2021- Nov, 2024
Experience
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MOLINA HEALTHCARE INC
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United States
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Hospitals and Health Care
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100 - 200 Employee
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Sr Specialist, Quality Intervention/QI Compliance
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Sep 2021 - Present
• Acts as a lead specialist to provide project-, program-, and / or initiative-related direction and guidance for other specialists within the department and/or collaboratively with other departments.• Implements key quality strategies, which may include initiation and management of provider, member and/or community interventions (e.g., removing barriers to care); preparation for Quality Improvement Compliance surveys; and other federal and state required quality activities.• Monitors and ensures that key quality activities are completed on time and accurately to present results to key departmental management and other Molina departments as needed.• Writes narrative reports to interpret regulatory specifications, explain programs and results of programs, and document findings and limitations of department interventions.• Creates, manages, and/or compiles the required documentation to maintain critical quality improvement functions.• Leads quality improvement activities, meetings, and discussions with and between other departments within the organization.• Evaluates project/program activities and results to identify opportunities for improvement.• Surfaces to Manager and Director any gaps in processes that may require remediation.• Other tasks, duties, projects, and programs as assigned. Show less
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Sr Specialist, HEDIS/ Quality Reporting
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Jan 2021 - Sep 2021
• Collaborates and / or assists in performing quality assurance checks on reports prior to completion• Develops and provides reports along with cost-benefit analysis tools to meet QI requirements• Ensures maintenance of programs for members in accordance with prescribed quality standards• Conducts data collection, reporting and monitoring for key performance measurement activities• Provides direction and implementation of NCQA accreditation surveys and federal/state QI compliance activities• Acts as a lead analyst to provide project-, program-, and / or initiative-related direction and guidance for other analysts within the department and/or collaboratively with other departments• Use automated software tools and processes to help streamline activities and improve data/analytics for the quality team• Develops, codes, runs, and/or prepares formatted reports to support critical Quality Improvement functions (e.g., reporting for key performance measurement activities, including HEDIS, state-based measure reporting and medical record review)Oversees, plans, and implements new and existing healthcare quality improvementinitiatives and education programs• Works with Director and / or Manager to establish and / or document quality assurance process checks to be utilized byall staff to ensure the integrity, completeness and validity of external and internal reports• Understands how to prioritize reports according to business need, regulatory requirements, urgency and / or other key business factors• Collaborates with department leads and other partnering departments to understand and / or document business requirements and / or implement required reporting• Coordinates data and analyses from MHI and / or Health Plans as needed • Assists with generation of State-specific performance measurement requirements• Assists program managers with research regarding performance measurement outliers when asked Show less
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Magellan Health
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United States
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Hospitals and Health Care
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700 & Above Employee
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Provider Support Coordinator
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Jul 2019 - Jan 2021
Assesses current practice patterns, assets and challenges utilizing NCQA, HEDIS, state and regulatory standards.Identifies action plans for providers to implement to improve cost, quality and the patient experience.Participates in design, development, and implementation of community learning forums.Actively participates in developing program recommendations and internal action plans. In provider office, schedules members for appointments to close HEDIS gaps in care and for follow-up after hospitalization.Establishes a project plan with the practice that establishes goals and objectives for improvement.Provides subject matter expertise Risk Adjustment for CMS HCC Medicare Advantage and/or Medicaid, Quality (HEDIS / STARS) measure performance, Population Health including population segmentation, risk stratification models, disease management and case management performance tracking and analytics.Provides ongoing practice support and sustains the partnership by establishing regular meetings to track progress. Provides orientation, training, education meetings, presentations and focus groups to improve mutual understanding and enhance working partnerships with providers. Improves member experience to positively impact CAHPS scores. Utilizes SQL, AWS, MRCS, Qlik and other BI and data tools to define, extract, validate, shape and interpret data to meet business needs. Assists with member survey. Train and assist Hedis Outreach MRR Team on HEDIS Measures and company systems.Responsible for identifying improvement opportunities for clinical initiatives through reporting and analytics. Provides education for practices to develop expertise with metrics and data review for quality improvement. Participates in various community and multi-department committees to assure effective program implementation.Coordinates on-site support in provider offices for completion of clinical interventions (Clinic Days).Provides member education. Show less
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Appeals Coordinator Senior
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Nov 2018 - Jul 2019
• Analyzes and renders final decisions of non-clinical appeals according to procedure, stateand federal guidelines, benefit plan guidelines, company internal policies and work flows.• Coordinates the appeal and dispute process through the collection of clinical records andconsultation with Physician Advisors/Medical Director and communicates final determination.• Familiar with and can assist in coordinating peer review scheduling involving internal• Physician Advisors and external vendors.• Consults with internal departments such as Clinical, Legal, and Network, as well as companysenior management to assure appeal and complaint decisions meet all guidelines and resultin customer satisfaction when possible.• Consults with Account Management and external vendors to resolve high profile, complexappeals and/or complaints.• Responsible for preparation of written detailed case history and presentation of second levelappeal cases to the Appeals Panel for final company determination.• Documents process and findings within the Appeals and the Complaint databases, andinternal systems.• Responsible for interface with members and providers as required regarding status, processand outcomes of complaints and appeals.• Responsible for maintaining the integrity of the company relationship with customers by• researching, resolving and responding to customer inquiries for appeals, disputes andscheduling issues.• Responsible for identifying risk situations, consulting with senior management staff andrendering determinations that could adversely affect the company.• Researches, compiles and consults with external review organization and customers asnecessary for appeals and complaint process. Show less
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Pediatrix Medical Group
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United States
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Hospitals and Health Care
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700 & Above Employee
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Billing Analyst
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May 2016 - Nov 2018
• Research and analyze the cause of all billing errors.• Work special project and perform testing for all system upgrades.• Perform coding.• Participates in Regional meetings for edit evaluation, as required.• Generate AR status report for each region and perform end of month process.• Daily review Claims Manager, OBR, Nextgen and GPMS edit report.• Responsible for ensuring that the Clinical staff is licensed appropriately in all states as determined by individual state regulations.• Monitor and track providers’ enrollment process until they are enrolled.• Place providers AR on hold until enrollment process is completed.• Release providers AR from hold once provider enrollment is complete and credentials are update correctly in the system.• Create spreadsheets obtaining data in order track what type of accounts are being reviewed.• Review and evaluates the contracts of healthcare providers network. • Run, update and monitor Ops report to inorder to maintain the amount of AR providers has outstanding. • Review errors with Associates and retrain as necessary. Monitor errors until resolved. • Identify opportunity for new edits based on billing analysis.• Balance Hash Totals and identify any skipped and duplicated batches.• Identify and report to IS any system issues.• Run billing error report daily.• Monitor and audit the billing control processes and operations.• Complete Daily edits report for Onbase scanning and Tie Out process of all interfaces.• Monitor daily EPM Exception report and work Practice to resolve any open issues.• Work with IS to achieve timely resolution of daily issues.• Analyze, Monitor, Control, and Audit the billing process through key indicator and data control reports to ensure the integrity of billing data.• Validate daily import of RDS/BS and weekly uploads from SoundData interface.• Validate daily ximport of data from OBR to GPMS and Nextgen. Show less
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Patient Account Specialist
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Nov 2015 - May 2016
• Research and analyze the cause of all billing errors.• Perform backup role for Billing Analysis.• Perform coding clean-up• Assist Manager in covering for employee absences and special projects.• Assist all departments with any issues they may have.• Run billing error report daily.• Review and Run providers AR reports• Daily review Claims Manager, OBR and GPMS edit report.• Review errors with Associates and retrain as necessary. Monitor errors until resolved. • Idenity opportunity for new edits based on billing analysis.• Balance Hash Totals and identify any skipped and duplicated batches.• Identify and report to IS any system issues.• Responsible for analyzing, reviewing, recovering, auditing and resolving clients’ accounts.• Work with IS to achieve timely resolution of daily issues.• Monitor and audit the billing control processes and operations.• Validate daily ximport of data from OBR to GPMS and Nextgen. Show less
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Insurance Collector II
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Jan 2011 - Nov 2015
• Research and document customers’ accounts accordingly• Responsible for processing and adjusting refunds, reconciliation’s pertaining to Third Party Billing• Recover overdue credit payments and work credit balance reports.• Perform writeouts offs on accounts if approved. • Reevaluates evidence and procures additional information in connection with claims under appeal or cases requiring investigation based on patients’ Insurance benefits with proper documents.• Process and collect accounts receivables.• Responsible for analyzing, reviewing, recovering, auditing and resolving clients’ accounts.• Track and trace checks issued to providers and clients to determine clearing status whether check cleared the bank, outstanding and etc. Stop payment on checks not received by providers or clients and reissue out payments accordingly.• Verify patient enrollment status and benefits with various Insurance carriers.• Contact customers and providers and discuss various avenues clients debts can be repay based on if customer has insurance such as Medicaid, Commercial, Manage Care , Medicare or self- pay for various states such as Maryland, Illinois, Indiana, Delaware, Iowa and etc. .• Run Crystal reports based on the information provided for patient account• Issue recovery letters to providers on hold requesting refund for outstanding negative balance. Show less
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Verizon
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United States
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IT Services and IT Consulting
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700 & Above Employee
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Consultant
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Aug 2008 - Nov 2010
• Responsible for analyzing, reviewing, recovering and resolving clients’ accounts. Answer high volume of calls from customers and other providers regarding billing statement, service, overpayments/underpayments, and customers’ information on file. • Sales and persuade clients to add additional products and services to new and existing accounts. • Research and document customers’ accounts accordingly • Responsible for processing and adjusting refunds, reconciliation’s pertaining to Third Party Billing • Track and trace checks issued to providers and clients to determine clearing status whether check cleared the bank, outstanding and etc. Stop payment on checks not received by providers or clients and reissue out payments accordingly. Perform routine research and investigations to obtain correct data to resolve inquiries. • Participates in Test and document solutions to make sure system is running properly. • Utilize documentation and user training in order to modify required business design created to input information into the system. Show less
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Anthem, Inc.
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United States
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Hospitals and Health Care
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700 & Above Employee
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Licensing Analyst I
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Feb 2007 - Aug 2008
• Responsible for ensuring that the Clinical staff is licensed appropriately in all states as determined by individual state regulations/Wellpoint. • ELT by administering the initial and renewal licensure process. • Ensure the Multi-State licensure process is initiated for all identified clinical staff in the Analysts area of responsibility. • Research and document RN business issues. • Examine and analyze data submitted by and/or on behalf of the clinical staff for licensure accuracy, authenticity, and completeness of factual information. • Complete licensure applications and forms accurately based on the knowledge of state licensing boards’ rules, regulations and requirements to ensure issuance of all required state licenses. • Obtain additional information and approval signatures from the clinical staff as required by the licensing boards. Run Crystal reports based on the information provided by the Rns. • Communicate with state licensing boards, local law enforcement agencies, other federal and state agencies, and other entities including professional organizations, hospital administrators, health care entities, general public, providers and other licensing and/or certification relative to status of licenses, compliance, statues, rules and regulations, and policies and procedures of the Board. • Maintain accurate database records and files for assigned clinical staff. • Advise the clinical staff of continuing education requirements of the various licensing boards and certification entities required for initial and renewal licensure/certification. • Team Lead Show less
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Beverly Healthcare
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Hospitals and Health Care
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1 - 100 Employee
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Medicaid Eligibility Specialist II
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Apr 2004 - Feb 2007
• Communicates determination of eligibility (approval or denial) to billing specialists, intake, social workers, administrator and ED. • Translates business requirements to staff to ensure that the customer’s requirements are entered into the system design. • Handle variety cases within the Fredericksburg, West Virginia, Maryland D.C. and Virginia area for Medicaid clients. • Research and document customer’s issues. • Contacts county intake worker weekly for application status and follow up as needed with facility social worker and/or resident’s agent to expedite process until determination is received. • Records and evaluates personal and financial data obtained from applicant or recipient to determine initial continuing eligibility, according to departmental directives. • Maintains tickler system for tracking re-certification due dates and contacts agent and/ or facility nursing staff to ensure timely reapplication and clinical assessments as needed. • Update patient liability changes (private portion listed on map 122) in Resident billing Maintenance. Run Crystal reports based on the information provided by the applicant. • Send weekly status report to ED on all pending applications that have exceeded the normal processing/approval time. Show less
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Commonwealth of Virginia
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United States
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Government Administration
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700 & Above Employee
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Claims Adjuster
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Sep 2003 - Apr 2004
• Adjudicates claims for benefits based on state and federal regulations offered under governmental social insurance program such as disabled workers, and etc pertaining to third party billing. Serves as liaison between state agencies, insurance adjusters, claimants’ and/ or attorneys regarding claims processing. Seek subrogation to collect reimbursement. • Analyze and evaluates data on documents and forms, such as claim applications, birth or death certificates, physician statements, employer’s records, vocational evaluation reports and other similar records. • Interviews or corresponds with claimants or agents to elicit information, correct errors or omissions on claims forms, and investigate questionable data. • Authorizes payment of valid claims, notifies claimant of denied claim and appeal rights. Reevaluates evidence and procures additional information in connection with claims under appeal or cases requiring investigation of claimant’s continuing eligibility for benefits. • Prepares written reports of findings. Specialize in one phase of claim program, such as assisting claimant to prepare forms, rating degree of disability, investigating appeals, and answering questions concerning filing requirements and benefits provided. Show less
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Education
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2003 - 2010
Strayer University
Master of Business Administration - MBA, Business Management -
2005 - 2007
Strayer University
Bachelor of Business Administration - BBA, Business Administration and Management, General -
2003 - 2005
Strayer University
Associate of Arts - AA, Business Administration and Management, General
Community
