The Risk Adjustment Forum features hand-picked renowned speakers in the industry to share unique perspectives to strengthen and evolve risk adjustment programs for Medicare Advantage, Medicaid, and Commercial health plans.
Carrie works on Paramount's Actuarial Team as a Risk Adjustment Analyst. She works on member and provider intervention programs for Medicare, Medicaid and ACA products and assists with claims submission processes, vendor management and ROI reporting. Carrie earned her Bachelors degree in Mathematics and Statistics at Miami University of Ohio and is currently working towards completing her MBA in Finance from the University of Toledo.
Lisa Balsam, BSN, RN, CPC, CRC Clinical Coding Educator
Ms. Balsam has over 20 years of nursing experience in both inpatient and outpatient medicine. She has been working and serving as a subject matter expert in the field of coding since 2015, and currentlyworks as the Clinical Coding Educator for the largest privately physician owned practice in Maine.
While monitoring CMS and other payer updates as they pertain to coding and billing rules and regulations,Ms. Balsam develops ongoing and ad-hoc educational coding-related curriculum/materials for 140 providers and 800 clinical staff on the business side of health care, coding and compliance. She continues to work as a liaison withthe Clinical Documentation Improvement Specialists/ Risk Coding department to find efficiencies, provide cross-training and cross-coverage opportunities.
“The world is changing and leaders must change with it. The days of "command and control" are over. People are demanding leaders who are emotionally intelligent and put the priorities of the people they serve above selfish ends. We call these "human-centric" leaders––and our movement is dedicated to developing, cultivating and supporting these leaders. Leaders are people who transform themselves through their experiences, opportunities and challenges to become the people others count on for inspiration, guidance and action.I’m a former drug addict and two time college dropout. I used to think that was a miserable resume for someone who trains leaders to be better people. I now know that it is the perfect resume! Here's why... Leaders are made, not born. I’llgo a little further, leaders are transformed. I transformed myself from a loser to a leader––from a drug abuser to a Black Belt, and later to Sensei. Over 25 years of teaching I helped hundreds of others transform themselves into Black Belts, and thousands more discover their best selves." Jim Bouchard is an internationally recognized speaker, Leadership Activist, and founder of The SENSEI LEADER Movement ™. He provides interactive keynotes and leadership programs for corporate and conference audiences around the world. Jim is a seasoned media guest, and appears regularly on TV and radio, including such programs as BBC Worldview and FOX News. He hosts Walking The Walk, a leadership podcast highlighting compassionate, engaged leaders from all areas of business, diverse cultures and experiences.He is a 2004 inductee to the U.S. Martial Arts Hall of Fame and was twice featured in "Inside Kung Fu"magazine.Jim is a volunteer mentor for incarcerated youth, an obsessive golfer and surf guitar player. In 2016 Jim was nominated to run for Congress.
Sean Creighton, Managing Director, is responsible for leading advisory services work tied to Medicare Advantage (MA), risk adjustment, and related issues. His extensive experience with claims data and application of Avalere’s modeling and analytics functions enable him to advise clients on their strategic goals.
Prior to Avalere, Sean was a Senior Vice President at Verscend Technologies, where he led the development and management of risk adjustment products. Prior to that, he spent 15 years at the Centers for Medicare & Medicaid Services (CMS), leading the policy development and implementation of major public programs.
Sean holds graduate degrees in Sociology and Statistics from the London School of Economics and Trinity College, Dublin, Ireland and a BA from University of Limerick, Ireland.
Dr. Shannon Decker is Vice President of Clinical Performance for Brown and Toland. Dr. Decker has more than 19 years of experience in healthcare--13 of which include working with risk adjustment and Medicare. Dr. Decker has a PhD. in Interdisciplinary Studies, dual MBA degrees--in Finance and in Marketing, as well as an M.Ed. in Secondary Education and a M.Ed. in Administration and Leadership. Dr. Decker is on the faculty at Arizona State University and is also an associate professor of Higher Education & Adult Learning (HEAL) and chief methodologist for Walden and Capella Universities where she chairs and oversees the dissertations of doctoral students. An author of two books and several peer-reviewed articles, she consults in both the fields of healthcare and education. Her interests include the study of human behavior and how theories on motivation and learning may be brought to bear on population health management.
Lisa J. Garrett, RN, BSN, CPC, CPC-I, CPC-P, CRC Risk Adjustment Manager
In 10/2018, Lisa joined Optima Health plan as the Risk Adjustment Manager in their newly formed Revenue Management department. Lisa leads retrospective and prospective activities for accurate and compliant documentation and coding efforts to ensure risk score calculation reflects the actual health status of members in Optima’s Medicare Advantage, ACA, and Medicaid risk adjusted lines of business. Lisa collaborates with the plan’s clinical care and quality departments to ensure alignment of HEDIS/Star performance and risk adjusted diagnosis coding gap closure.
Lisa has been a team coordinator in the Population Health Management department managing a small team of coders focused on ambulatory clinical documentation improvement for Medicare Advantage risk adjustment
Lisa has extensive experience in clinical operations, hospital chargemaster, healthcare charge capture, revenue integrity concepts, ICD-10-CM, and CPT/HCPCS coding concepts. She has been a physician coding and auditing specialist conducting E&M and operative report audits for a children’s multispecialty surgical group.
Lisa has been an AAPC certified CPC instructor since 2005.
Lisa was an adult critical care nurse for over 10 years, working in areas such as open-heart surgery ICU, surgical-trauma ICU, neurology ICU, and CCU.
Lisa will graduate in 2020 from VCU with a Master’s degree in Health Administration. Lisa has a Bachelor of Science in Nursing with a minor in biology.
Lisa enjoys practicing yoga and spending time with her mother and life-partner of 24 years, Bryant.
Colleen Gianatasio, CPC, CPC-P, CPMA, CPC-I, CRC Director of Ambulatory CDQI
Mount Sinai Health Partners
Colleen Gianatasio CPC, CPC-P, CPMA, CPC-I, CRC has 18 years of experience in the health insurance field. She has experience in customer service, claims, quality and coding. As Risk Adjustment Quality and Education Program Manager for Capital District Physician’s Health Plan (CDPHP) Colleen’s primary responsibilities are provider engagement and clinical documentation improvement for accurate coding. Colleen specializes in developing innovative coding curriculum and instruction to support compliance with federal guidelines and appropriate reimbursement processes. She is a certified AAPC instructor and enjoys teaching a variety of coding, documentation and auditing classes. Colleen serves as President-Elect of the AAPC National Advisory Board.
Steven Graessle, CPC, CRC, CPMA Compliance Review Specialist
St. Elizabeth Physicians
Steven has worked in the Risk Adjustment field for 5 years at St. Elizabeth Physicians. Steven's responsibilities in the Coding and Education department include educating providers on HCC Coding and documentation as well as developing new processes to direct information from the insurance companies to the providers. Previously Steven worked in provider education for an orthopedic office.
Steven earned his Bachelors in Business Administration from Northern Kentucky University and is also a Certified Professional Coder (CPC), Certified Risk Adjustment Coder (CRC), and Certified Professional Medical Auditor (CPMA).
Ana Handshuh, CHC, is a government programs executive with expertise in creating and implementing corporate programs for the healthcare industry. Ms. Handshuh is the Principal at CAT5 Strategies, a healthcare advisory practice specializing in Regulatory and Operational Compliance, Revenue Management, Communications, Quality, Care Management Programs, Benefit and Formulary Design, Program Bid Submission, Accreditation, and Technology Integration. She recently founded TRACSCOUT, a technology startup SaaS platform for managed care processes.
Her recent consultancy roles include conducting compliance risk assessments, performing Compliance Program Effectiveness audits, conducting FDR and PBM pre‐delegation audit, preparing for CMS program audit, and writing and implementing post‐audit corrective action plans. Ms. Handshuh has also assisted government program sponsors achieve higher Star ratings, create and implement care management programs, document their processes and procedures, achieve accreditation status, design and submit government program bids, institute corporate‐wide programs and create communications strategies and materials. She is a member of the Health Care Compliance Association and is Certified in Healthcare Compliance by the Compliance Certification Board. Ana currently serves on the Board of the Resource Initiative and Society for Education (RISE), the preeminent national professional association dedicated to managed and accountable care financing and delivery.
Ms. Handshuh previously served as the Vice President of Managed Care Services at Central Florida Inpatient Medicine (CFIM), providing leadership and strategy on CFIM projects with physicians, risk entities, hospital systems, and health plans. Prior to that assignment, she worked with Precision Healthcare Systems as their Vice President of Quality Improvement, leading the IPA’s collaborations with payers to implement Quality and Star Rating initiatives. Ms. Handshuh also served as the Director of Corporate Program Development at Physicians United Plan (PUP), leading the Medicare health plan’s Quality Management and Corporate Communications departments and spearheading the development of innovative integrated technology solutions to drive business excellence and Star Rating achievement. Prior to joining Physicians United Plan Ms. Handshuh was the founder of I-Six Creative. Under Ms. Handshuh’s vision and leadership, I-Six provided expertise in the areas of managed Medicare benefit design, MSO/IPA operations, provider network strategy, new market launches, technology integration, corporate communications and quality improvement.
Eric Harman has been board certified in Family Medicine since 2000 and a member of Mountain Region Family Medicine (MRFM) in Kingsport, TN, since 2002. Presently Dr Harman serves as MRFM's IT Committee Chairman and board President. He is a graduate of University of Maryland College Park and East Tennessee State University College of Medicine. He has been active in population health improvement projects through committee work with Highlands Physicians IPA, Qualuable ACO, and through MRFM’s participation in Medicare Advantage shared savings programs. He enjoys spending time with his wife and 3 kids in his spare time and also travelling.
Dan is the founder and General Manager of The EDI Project™ a company that specializes in helping health plans and healthcare informatics companies consume and make meaningful even the most complex healthcare data. While he has been working with healthplans since 1997 in areas such as claims automation, record retrieval and quality measurements, Risk Adjustment drew him in a decade ago with the need for expertise around EDI when it came to Encounter Data Processing. Dan spends a good deal of time working with organizations to help understand the areas and underlying data sources that cause differences in their risk adjustment data from what they expected, RAPS results and what CMS is reporting for results in EDPS data. Dan is also the CEO of AnonEDI™ an anonymization engine for PHI data which helps companies easily strip PHI from complex data files for testing, development or analytics while still maintaining record integrity or anonymous personhood.
William Jonakin, MD, CPC, CRC
Medical Director, Medicare Advantage and Risk Adjustment
William Jonakin, MD, CPC, CRC Medical Director, Medicare Advantage and Risk Adjustment
St. Luke's Health Partners
Dr.Jonakinhas had a career spanning several areas: Pediatrics, Emergency Medicine, Urgent Care, and General Practice. He has always been interested in the business of medicine, and most recently the shift from volume to value. He is the Medical Director for Medicare Advantage and Risk Adjustment at St. Luke’s Health Partners, a financially and clinically integrated network in Southwest Idaho. He is also the principal in Clinical Discernment, LLC, a consultancy focused on the accurate representation of the illness burden of a population. Dr.Jonakinis board certified in Pediatrics and is also a Certified Professional Coder and Certified Risk Adjustment Coder.
Deniese Scheff‐Crittenden, a Senior Consultant for Dynamic Healthcare Systems, is a subject matter expert on Risk Adjustment. In this role, Deniese leads Dynamic’s risk adjustment segment of business supporting development, operations, and account management to provide gap analysis, assessment, design and implementation in managed care risk adjustment activities. She provides leadership to ensure delivery of Dynamic’s services to ensure client program compliance and quality, risk mitigation, integration of critical data to support clinical and revenue management performance outcomes and accurate revenue realization. Deniese provides a unique perspective having worked for both Provider and Payer organizations. She brings Dynamic Healthcare Systems more than 12 years of experience in the Medicare/Medicaid industry as well as more than 25 years of healthcare experience as a Registered Nurse and a Geriatric Social Worker.
As a former Director of Risk Adjustment, Deniese has supported start‐ up Medicare Advantage health plan operations for all aspects of Risk Adjustment: clinical coding support and quality documentation provider outreach programs, policy and procedure development, design and strategy development for RA activities. Denies has a proven track record with developing scalable Risk Adjustment program and organizational alignment with Population Health Management and HEDIS/Stars initiatives to drive quality improvement, program compliance, contain healthcare costs and ensure revenue realization.
Deniese previously served as a high risk Obstetrical Nurse and a Geriatric Social worker. She holds a Bachelor of Arts Social Work from Michigan State University, Master of Science Nursing and Healthcare Administration from University of Phoenix.
Deniese enjoys hiking, biking, organic gardening and cooking and world history, culture and travel.
Caralyn has worked in the Risk Adjustment field for over 6 years and previously led the Risk Adjustment Quality department at a local health plan serving both the Commercial and Medicare markets. Caralyn developed and managed an effective quality assurance program which included Risk Adjustment documentation and coding education and led initiatives to reduce inefficiencies throughout the integrated delivery network.
Caralyn earned her Bachelor of Health Science at the University of Florida and is also a Certified Professional Coder (CPC).
Donna Malone, CPC, CRC
Director of Enterprise Risk Adjustment: Coding and Provider Education (CDI)
Donna Malone, CPC, CRC Director of Enterprise Risk Adjustment: Coding and Provider Education (CDI)
Tufts Health Plan
Donna has been on the job with the Tufts Health Plan in their senior products division since August 2014, and is responsible for audit and coding review management, development and implementation of department and vendor policies and procedures, simulation RADV Audits for preparedness, coding team performance management and provider education development and management. Additionally, Donna serves at the MassBay Community College in Framingham, where she has been an advisor / professor for nearly 10 years. Her specialty area is the Medical Coding Certificate and Medical Office Administration Program.
Prior to Tufts Health Plan, Donna worked for Blue Cross Blue Shield of Massachusetts as an HCC Professional Audit III for four years. Earlier, she worked for AM B Care for 9 years and Maine Medical Center.
Amber Malone-Wright, RHIT, CPC, CDEO, CPMA, CRC, CPC-I, CEMC, CCMA Manager of HCC Coding & Encounter Data
I have been in healthcare for 16 years, working clinically under teaching physicians in OBGYN and Internal Medicine. I have been working in Risk Adjustment since 2010 and became a Certified Professional Coder in 2013 and have been in RA ever since. I have worked for IPA’s (independent physician associations) managing risk and assisting with HEDIS for multiple payers including UHC, Humana, Care-N-Care, and ACO’s, along with independently educating physicians and coders on Clinical Documentation Improvement (CDI) as value-based contracts continue to evolve, and now passionately working for CHRISTUS Health Plan to improve Risk Scores and financial revenue.
Gabriel McGlamery J.D.
Sr. Health Policy Consultant, Government Relations
Gabriel McGlamery J.D. Sr. Health Policy Consultant, Government Relations
Gabriel McGlamery is in charge of Federal regulatory policy for Florida Blue’s individual market business. This means analyzing, influencing, and general problem-solving for the insurer covering roughly 10% of Marketplace enrollment. Prior to joining Florida Blue in 2012, Gabriel helped develop the rules for the ACA at HHS and graduated with honors from the University of Connecticut School of Law.
Dave is a strong leader with 14+ years of experience in Revenue and Clinical Outcomes Program Development and Management in various healthcare environments (Plans, MG/IPA, Academic, and Consulting). Proven record of success in optimizing Operations, PE / Investor Meetings, Maintaining Compliance, Recovering / Maximizing Revenue, Enhancing Clinical Quality and Developing Software and Custom Analytics. Specialties: RA / HCC, Pay for Performance (P4P), CMS Stars Program, NCQA HEDIS, Off‐shore Software Product Development, HOS, CAS, NCQA Accreditation, Physician Profiling, Encounter Programs, Contract and Claims Analytics. Previously, Dave served as an independent consultant to healthplans, was Corporate VP, Operations (Revenue and Quality) at InnovaCare Health. He has also performed as Sr. Consultant, Risk Adjustment and Health Plan Operations for Dynamic Healthcare Systems, and in other roles with healthplans.
Andrew Perlstein Vice President of Client Services
Andrew is responsible for Episource's Client Services division and ensures that client organizations derive maximum value from their Episource partnerships. He has over 15 years of client relations experience in the health care industry and has held a variety of leadership roles with McKesson Corporation, RelayHealth (a division of Change Healthcare), and The Advisory Board Company. Andrew earned his Bachelors degree in political science and Spanish from Duke University
Kenneth PersaudMDis a physician executive with diverseleadershipexperienceacrosshealthcare sectors, including roles in integratedhealthcaredelivery systems. Ken hasdedicatehis career to developing teams witha provenability to innovate and achieve remarkable success invalue-basedhealthcare models. A hallmark of Ken’scareerhas been contributing tovertically integrated healthcare; focusing onre-design,equitablecost, physician compensation,and population management;all towards accelerating performance,andcreatingvalue for patients, health plans, physicians, hospital systems and investors. Dr Persaudis theCEO of Visualize Health, based inFranklin,Tennessee. Visualize Health isphysician network andhealthcare managementcompany with an innovativepopulation health technologyplatform, whichdelivers solutions tophysician networks and payers, helping foster self-sufficiency by creating sustainable revenue models while transitioning to value-based programs, and preparing forrisk basedreimbursement.Dr Persaudearned a Bachelor’s of Science from the Rochester Institute of Technology, NY andcompleted his post graduate trainingat theUniversity of Mexico, School of Medicine.
Having grown up in Iowa, Dean decided to become an Actuary in 2004. In 2012 he attained the Fellows designation and now enjoys education continuously, year after year. Something about keeping a credential.
His work in health insurance encompasses claim operations, provider credentialing, risk score optimization and a wide variety of Actuarial responsibilities. He has worked on most lines of business although is most familiar with Medicare Advantage, Individual and Small Group.
Dean works as an Actuarial Director for Optima Health Plan, a provider-owned plan located in Virginia Beach, VA. His current focus is realizing Optima's risk adjustment function.
His innate personality lends itself to copious information consumption and rigorous analytical approaches. He wonders why there are only seven levels of why when there's so much more to be understood.
Bahar Sedarati, MD, FCUCM National Medical Director
A physician executive with diverse experience across the continuum of care, including private medical practice, medical group management, integrated delivery system leadership, and payers.
The national expert in clinical documentation and utilization management with an MCG Utilization and Case Management certification. Additionally, she is physician trainer on HCC Risk Adjustment Model, inpatient, and outpatient clinical documentation, DRG validation, as well as utilization management, with a niche in training providers on harvesting data to achieve precision in utilization and higher pay per performance.
She is also the Fellow of Collage of Urgent Care Medicine, certified in urgent care management, CUCMP, and on-demand care with over a decade of running successful medical practices in Southern California as Chief Executive Officer of startup primary care and urgent care practices.
Bahar is a dynamic speaker, and an engaging educator. She is passionate in formulating creative ways to make connection with fellow physicians and has created many innovative tools empowering them to succeed in the value-based care space and reach the quadruple-aim by creating value not only for the patients but also their practice.
Naomi Senkeeto is a Managing Director, Policy at the Blue Cross Blue Shield Association (BCBSA) where she leads policy development for ACA-related financial management and payment policy issues (including the risk mitigation programs, marketplace subsidies and payment processes, and reconciliation and data integrity), as well as the Federal budget and appropriation processes. She also provides analytic and strategic advice on a variety of other ACA-related issues. Prior to joining BCBSA, Naomi served as a Senior Analyst in the Office of Health Insurance Exchanges at the Center for Consumer Information and Insurance Oversight (CCIIO) in the U.S. Department of Health and Human Services, where her responsibilities included analyzing and developing marketplace regulations and guidance. Prior to CCIIO, Naomi was the Associate Director for Policy and Strategic Alliances at the American Diabetes Association, during which time she also served as an appointed member of the Consumer Liaison Committee of the National Association of Insurance Commissioners (NAIC). She also has held policy positions with the American College of Physicians, Reproductive Health Technologies Project, and the American Association of University Women. Naomi received her Masters of Public Policy from the George Washington University and has a BA in Political Science from Rutgers University.
Laura Sheriff, RN, MSN, CPC, CRC National Director, Risk Adjustment
Molina Healthcare, Inc.
Laura leads a dynamic Risk Adjustment Team, managing the day to day operations for Medicare and Marketplace members. She has a proven track record of maximizing risk scores. Laura designs and coordinates all team activities which focus on provider education, training, auditing, data mining, and data analysis to steer program success and achieve performance metrics. Laura is familiar with developing strategies for seeing high risk members utilizing technical dashboards, auditing processes, and working 1:1 with local vendors. Additionally she identifies end-to-end processes and prioritizes interventions to correct known weaknesses. Laura also provides support to corporate compliance efforts for RADV audits for both lines of business. She collaborates with business partners and develops best practices, and shares them with other health plans.
She has over 20 years of varied clinical nursing practice experience including more than ten years of Clinical Coding Certification practice. Laura is a Master’s prepared nurse, who also maintains her CPC and CRC through the AAPC.
Mandvi Tandon Senior Manager of HCC RA Provider Education
Cedars-Sinai Medical Center
Senior Manager of Risk Management, Cedars Sinai Medical Network Services Mandvi’s background in risk adjustment has been over 10 years. Her experience in risk adjustment has been demonstrated in helping providers in New York and southern California raise their RAF scores through a systematic HCC education program. Mandvi, has raised the scores of multiple groups that she has worked with from senior memberships of ~5,000 and above raising their RAF average from a 0.8 to a 1.3 within a year through the 3 step HCC Education program she teaches. Ensuring each provider that undergoes the training learns to document & code appropriately based on CMS guidelines to reflect the true burden of illness. Mandvi has experience on working on the health plan and the provider group side: IPA & staff model. She is passionate about the works she does and believes in making a unique connection with each provider that she works with to help drive their success!
Christie Teigland, PhD Principal, Health Economics & Advanced Analytics
Dr. Teigland, Principal, Advanced Analytics, leads the design and implementation of statistical studies focused on comparative effectiveness, predictive analytics, and performance measure development and testing at Avalere Health. Dr. Teigland has served as Principal Investigator on several impactful projects comparing Medicare Advantage to traditional Fee-for-Service Medicare, including a grant from the Commonwealth Fund, and serves on the newly formed National Quality Forum (NQF) Scientific Methods Panel and NQF Standing Committee on Disparities, as well as the Pharmacy Quality Alliance (PQA) Quality Measure Expert Panel. Christie served as Senior Director, Statistical Research at Inovalon before joining Avalere where she managed performance measure development projects awarded by the National Committee on Quality Assurance (NCQA), URAC and others.
Dr. Teigland was Vice President of 2020 Initiatives and Director of Research at Leading Age New York for more than 10 years where she directed development of innovative technology solutions to advance the use of data-driven decision making to improve outcomes and reduce healthcare costs. She served on CMS technical expert panels including Nursing Home Quality Measures, Five Star Quality Rating System, and field-testing of AHRQ CAHPS satisfaction and patient safety tools, and on national expert panels including a RAND group that prioritized national patient safety measures; AHRQ Care Planning Expert Panel; MDS 3.0 Validation Panel, a CMS funded project to set national performance goals, and the NYS QIO Steering Committee. Dr. Teigland received her Ph.D. and M.A. in Economics from the University of New York at Albany and has a B.A. in Management Science and Economics from Moorhead State University.
Adele Towers, MD, MPH, FACP, CRC
Associate Professor of Medicine and Psychiatry, Director, Risk Adjustment,
UPMC Enterprises, University of Pittsburgh, School of Medicine, Division of Geriatric Medicine
Adele Towers, MD, MPH, FACP, CRC Associate Professor of Medicine and Psychiatry, Director, Risk Adjustment,
UPMC Enterprises, University of Pittsburgh, School of Medicine, Division of Geriatric Medicine
Dr. Towers is the Senior Clinical Advisor for UPMC Enterprises. She is directly involved in the development of healthcare related technology, with emphasis on use of Natural Language Processing (NLP) for Risk Adjustment coding and use of Clinical Analytics to optimize clinical performance. Prior to this role, she has served as the Medical Director for Health Information Management at UPMC with responsibility for Clinical Documentation Improvement as well as inpatient coding denials and appeals. She has been on the faculty in the Division of Geriatric Medicine at the University of Pittsburgh for over 25 years, and continues to see patients at the Benedum Geriatric Center in UPMC. She is the former Medical Staff President at UPMC Presbyterian, and her prior positions have been as Vice Chair for Quality Improvement and Patient Safety for the Department of Medicine, Medical Director of UPMC Home Health, Medical Director of the Benedum Geriatric Center and Medical Director of Primary Care at the Western Psychiatric Institute and Clinic. Dr. Towers has presented the experience at UPMC with use of NLP for coding at multiple regional and national conferences.
Tina Kim Tressler Manager of Coding and Chart Operations
Prominence Health Plan
Tina Kim Tressler is the Manager of Coding and Chart Operations for Prominence Health Plan in Reno, NV. She is originally from New Jersey where she obtained her Bachelor’s Degree in English at Rutgers University. She started her career in New Jersey as a Certified Professional Coder and Medical Biller in 2010 and managed and oversaw all billing and coding operations for a multimillion dollar medical billing company for four years before transitioning to Nevada. Tina joined Prominence Health Plan as their very first ever Risk Adjustment Coder and second member of the Risk Adjustment Department, which has now grown to 18 members. At Prominence Health Plan, Tina supports various initiatives from Risk Adjustment to STARS and HEDIS by managing the Risk Adjustment Coding Department and the Chart Operations Team who retrieves thousands of records each year from across the provider network. She has successfully trained new Risk Adjustment Coders while also learning and training HEDIS abstraction. She has also successfully lead the RADV Audit since 2017. Tina Kim currently resides in Sparks, NV with her husband, Dennis Tressler, and dog, Nutello.
Susan Waterman, RHIT, CCS, CPC, CRC Director, Risk Adjustment
Scott & White Health Plan
As Director of Risk Adjustment, Susan Waterman has been empowered to plan, design and oversee business and strategic objectives in creating and optimizing a Risk Adjustment Department responsible for ensuring the accuracy of risk adjustment payments while successfully managing all activities related to Medicare Advantage, ACA and Exchange Risk Adjusted lines of business. In that capacity Susan directed department changes that resulted in multi‐million dollar gains in ACA Risk Adjustment, brought all chart review activity in‐house saving 500K per year in vendor coding fees, and partnered with the hospital CDI/Quality Physicians to create an Outpatient CDI Department focused on documentation quality, Risk Adjustment activities and clinic training for 1,200 providers.
A proven leader in her field, Susan’s professional experience includes coding and compliance management, auditing and provider training, system management, and consulting services.
Monica Watson, RHIA, CPC, CCS, CCS-P, CPMA, CIC, CRC, CDEO Director of Coding
Centauri Health Solutions
As Director of Coding Services for Centauri Health Solutions, Monica Watson has over 15 years of handson experience in coding, auditing, operations, and leadership for providers, facilities, and health plans. Ms. Watson has created and maintained best practices for correct coding, has designed and implemented audit programs, including CMS‐RADV, HHS‐RADV, Inpatient DRG, Outpatient OPPS, and Due Diligence. Monica has also assisted in designing and implementing new coding and auditing software. Ms. Watson holds a Bachelor’s degree in Health Information Management from the University of Cincinnati and serves on the AHIMA Practice Council for Clinical Terminology and Classification.
Daniel Weaver is an established leader with extensive experience developing and implementing intervention strategies to improve Medicare Stars performance. With demonstrated success with innovative intervention programs, Daniel led a Stars Quality team at Highmark, Inc for 6 years where they consistently delivered market-leading performance and forward-thinking engagement with providers and members. Daniel moved to Gateway Health Plan to help move an underperforming DSNP plan to 4 Stars, boost Quality Improvement performance across multiple State pay for performance programs, and expand Risk Adjustment programs.
Scott has demonstrated experience at the executive level in Managed Care, HMO and IPA with increasing responsibility for financial and operations management with emphasis in data collection and analysis, budgeting, forecasting and strategic planning. Scott’s proven experience has been in the deloyment of RADV audits as well as developing and applying models for Medicare Risk Adjsutment, STARS, HEDIS and pay-for-performance programs.
Joe Wilson Enterprise Business Architect, Risk Adjustment
Joe has over three decades experience in software engineering and technical product management. He has expertise in several technical fields, including Risk Adjustment, Cloud Computing, and Image Processing. In over four years at WellMed, Joe has served as the Senior Director of the Risk Adjustment Product team, and has recently been promoted to the role of Enterprise Business Architect. In his current role he leads a team that sets the long-term business and technical strategy for the WellMed Risk Adjustment platform.
I have been in the medical field 40 years. I have worked in doctor’s offices starting as a receptionist and working my way up to Office Manager and Administrator for Primary Care as well as a few different specialties. I have been coding since the 80’s but became a CPC (Certified Professional Coder) in 2003. I also am a CPC‐I (Certified Professional Coding Instructor), CPMA (Certified Professional Medical Auditor) and CHCCS (Certified HCC Specialist). I am also an ICD‐10 certified trainer. I have been in management for 25 years and the last 13 years have been working for Medicare Advantage Health plans as Director Risk Adjustment Audit and Education. I now have my own consulting business, Susan Wyatt HealthCare Consulting Inc. My specialty is educating clinicians, coders etc. on the Medicare Risk Adjustment HCC model. I focus on the clinicians to educate them on proper documentation and coding for ICD‐10 diagnoses as it relates to HCC. I also do focus chart audits for Risk Adjustment HCC with analysis and educational feedback to the clinician. I have experience with RADV’s as well. ICD‐10 tools is a specialty of mine as well.