4 years ago

Response to RFP No. MED13002 State of West Virginia ... - DHHR

Response to RFP No. MED13002 State of West Virginia ... - DHHR

Request For Proposal #

Request For Proposal # MED13002 Recovery Audit Contract – Pharmacy West Virginia Health and Human Services Federal, and BMS‐specific requirements regarding processing capacity, security, and corporate compliance. In Addition, Pamela ensures that PRGX has the capability to interface with the State’s data systems (MMIS) to securely transfer large data files. Code Staff Manager: Patricia Dear, RN (Resume attached) Patricia will be the Code Staff Manager and has over 35 years in the Healthcare Industry. Patricia is certified by the American Academy of Professional Coders. Patricia leads our Medical Review/Utilization unit which consists of Clinical professionals with at least five years of experience in medical utilization review. Our Medical Review/Utilization (MR/U) staff possess, at a minimum, a bachelor's degree in nursing and/or social or health service with an active Registered Nurse license; or other medical certification sufficient to meet the requirements of the position (e.g. Physician’s Assistant, Paramedic, Dentist or Registered Dental Hygienist, etc.). Each member of our MR/U staff has extensive working knowledge of conducting Medicaid provider audits and possess the ability and skills to appropriately interpret the State’s Medicaid regulations and policies. Customer Service Manager: Ileana Starwood (Resume attached) Ileana Starwood has more than 15 years customer service experience with expertise in process improvements, including education, communication and roll‐out; training, performance management and problem resolutions. Ileana holds a Bachelor Science degree in Business Management ‐Health Information along with post‐graduate certifications in Professional Counseling and Executive Leadership and Management. At PRGX, Ileana’s responsibilities include maintaining a fully functional and appropriately staffed customer/provider services center. Ileana brings to this contract a deep and broad understanding as well as hands on experience in ensuring effective customer/provider services as required by West Virginia. Under Ileana’s supervision, we maintain well trained, knowledgeable and appropriately credentialed Customer Service Staff. Statistician – Sally Reeves (Resume attached) As a Statistician, Sally has more than 20 years of experience consulting on health insurance issues, from both the employer and payor perspective. Her specific experience encompasses a wide variety of underwriting and actuarial functions. In addition, Sally has a wealth of knowledge in the areas of managed care operations, claims auditing and statistical sampling. She is also a Certified Fraud Examiner (CFE). 49

Request For Proposal # MED13002 Recovery Audit Contract – Pharmacy West Virginia Health and Human Services PRGX Audit Staff Our audit staff is comprised of various certifications such as registered nurses (RN’s), registered health information technicians (RHIT’s), registered health information administrators (RHIA’s) – legal nurse consultants, certified professional coders (CCS, CCSP, CPC, CPC‐H). Our highly qualified team of healthcare auditors has over 20 years of industry experience with an average of 10 years of healthcare audit experience. Our statisticians and clinical analysts have extensive experience in examining health care claims for possible aberrancies. They work with the clinical staff in developing focused review concepts (both service and provider focused). All of our clinical data analytics teams have prior experience as Medicaid and Medicare contractors, PSCs/ZPICs, MICs, DOJ (Health Care Fraud) and have significant experience in identifying those areas most vulnerable to improper payment Our team’s professional affiliations include the American Health Information Management Association (AHIMA, Association of Certified Fraud Examiners (ACFE), the National Committee for Quality Assurance (NCQA), and American Academy of Professional Coders (AAPC). Approach to Staff Retention At PRGX we believe that retaining our core staff requires more than simply increasing salaries and refining their benefits package; although we know that our compensation and benefits package are very competitive. PRGX’s dedication to retaining top talent is built on a combination of attractive rewards, career development opportunities and work‐life balance. We offer incentives that matter to our staff. PRGX makes staff continuity a constant priority to ensure the long‐term success of not just our organization but our clients’ organizations through successful engagements. We believe that constant turnover severely impacts critical projects. To ensure continuity, PRGX takes proactive steps to retain our valued talent. PRGX’s talent management initiative ensures that we provide the performance management, succession planning, objectives setting, learning and development and recognition to retain our top talent. PRGX’s Talent Management and Retention Initiatives currently include: ♦ Competitive pay and benefits to attract and retain top talent ♦ Education Assistance Program ♦ Matching 401k plan to assist our employees with their retirement goals 50

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