Wynda Clayton, MS, RHIT
Jeff De Los Reyes
Dr. Adele Towers
Erika Bergstresser currently is the Director of Risk Analytics for Gateway Health Plan in Pittsburgh, Pa. She has 8 years of Risk Adjustment experience with both Medicaid and Medicare Advantage plans. Erika is experienced in building and reengineering Risk Adjustment programs, for a national plan and well as a regional plan. She began her career at Humana after teaching herself to become certified in coding.
As the Director of Risk Adjustment, Programs & Audit at SCAN Health Plan, Antonette is responsible for the overall performance of Risk Adjustment in her organization. In this capacity, she oversees all risk adjustment audits including those that are mandated by the state and the federal government. She has 15 years of solid healthcare experience in the Medicare and commercial lines of business.
Puneet is a Chief Actuary and Senior Vice President with CDPHP (Capital District Physician’s Health Plan). CDPHP is a top-rated non-profit health plan in the Albany NY area. Puneet has more than 15 years of actuarial work experience. As the Chief Actuary of CDPHP, Puneet assumes all actuarial responsibilities for the Value Based Contracts, Medicare, Medicaid and Commercial lines of business.
Gaurish Chandrashekhar is the Director of Revenue Management for the Finance department at Harvard Pilgrim Health Care. In this role, he is tasked with developing and leading a team to pursue risk adjustment revenue opportunities for Harvard Pilgrim's Medicare and Commercial lines of business by deploying effective prospective and retrospective initiatives. He joined Harvard Pilgrim in 2001 as a Sr.Analyst and grew through the ranks to the position of Manager, Pricing Applications. In his current role, he reports to the SVP & Chief Actuary.
Gaurish graduated from Southern New Hampshire University (previously New Hampshire College) in 1999 with a Masters in Computer Information Systems. Prior to immigrating to the United States, he completed his Bachelors in Engineering from University of Mumbai in 1994 and his MBA in Finance from ITM, Mumbai in 1998.
Outside of his day job, Gaurish is a professional percussionist and actively performs, records and teaches the fine art of Southern Indian drumming. His students have won awards at various national-level competitions. He has conducted lecture demonstrations at institutions such as Berklee College of Music and recorded for Boston Symphony Orchestra's web project. He was also one of six recipients of the Massachusetts Cultural Council's 2014-2015 Traditional Arts Apprentice grant program, as a Master artist. Gaurish resides in Newton, Massachusetts with his wife, Raina.
Wynda Clayton, MS, RHIT
Wynda Clayton is a Risk Adjustment Manager at Providence Health Plans in Beaverton, OR. She received her Health Information Degree from College of Saint Mary’s, her BS in Health Care Management from Bellevue University and her MS from Clarkson College. Wynda has been in the health care field for over 25 years with experience on all phases from compliance to billing and reimbursement to coding to Quality Assurance to being a RADV Auditor to risk adjustment and providing physician education. Wynda is very enthusiastic and loves basketball, traveling and helping those unfortunate. To help is not always meaning to give, but it also means to teach others how to make a difference in their lives. Currently Wynda resides in Portland, OR with her husband Kevin. She can be contacted at [email protected]
Dr. Hayes is currently with Highmark, Inc. in Revenue Program Management as the Manger for Quality, HEDIS and Coding. She has over 28 years’ experience in the healthcare industry spanning roles as both a provider and reimbursement manager. She has extensive knowledge in the areas of clinical quality, healthcare leadership, compliance, risk revenue, HEDIS and documentation improvement. She continues to publish and speak nationally for professional organizations on topics related to improving care delivery and documentation accuracy to optimize appropriate reimbursement.
Aldiana Krizanovic is the Senior Health Policy Consultant for Federal Government Relations at Florida Blue. In her prior role she served as a Health Policy Analyst for the Florida Blue Center for Health Policy. She holds a Master's in Public Health with a concentration in Health Policy from the University of North Florida. She specializes in Medicare regulation, with a focus on Medicare Advantage and Part D. In her role she monitors and analyzes Medicare regulatory changes and their impact to the business. Aldiana is passionate about advancing development of health policy that improves access to care for vulnerable populations, decreases cost of care, and improves individual's quality of life. She serves as an advisor to the Age-Friendly Public Health System Advisory Committee led by Trust for America's Health and the John A. Hartford Foundation.
Andy has more than 10 years of experience driving innovation and solutions that are used by patients, providers and payers worldwide.
Jimmy is a risk adjustment expert in risk scoring models and risk adjustment methodology. He is an industry thought leader who has spent over twelve years helping health plans across the nation better understand and formulate their risk adjustment strategies. Jimmy also has extensive experience in software programming and application design spanning across healthcare and financial institutions, and including time at a regional Blues plan.
Jeff De Los Reyes
Jeff De Los Reyes is a Senior Vice President of Healthcare Analytics and Risk Adjustment
Solutions at GHG. In this role, health plans and providers look to Jeff to provide Consulting
services to enhance, optimize, and ensure superior outcomes related to revenue accuracy and
compliance across all Government and State Sponsored Programs (Medicare, Medicaid, and
Jeff brings over 15 years of healthcare experience focusing on all areas of risk adjustment including developing comprehensive and complementary retrospective and prospective programs, ensuring accurate and complete encounter data submissions, and supporting revenue projections for Actuarial and Financial reporting. His experience includes developing strategies and initiatives to optimize health plan and provider risk adjustment operations and ensure compliance with Federal and State regulations. Jeff also brings valuable experience and industry insights in using data and analytics to drive successful outcomes and implementing technology solutions for risk adjustment programs including the use of Natural Language Processing and provider EMR integration. In addition, Jeff has helped to structure and design value based provider contracts and provider incentive programs to drive improvements in quality and premium revenue accuracy.
Prior to joining the GHG team, most recently, Jeff was responsible for enterprise risk adjustment, revenue management and encounter data submissions at EmblemHealth. He led the health plan strategy, redesign, and execution of a comprehensive end-to end risk adjustment program across Medicare Advantage, Medicaid, and ACA membership. He was accountable to provide leadership to a cross functional team to ensure successful outcomes related to clinical documentation improvement and provider engagement initiatives, encounter data integrity and submissions (RAPS, EDS, EDGE and Medicaid), compliance support, revenue projections, and chart review and abstraction.
Prior to EmblemHealth, Jeff spent 8 years at Optum in a variety of risk adjustment roles at OptumInsight including leading product and program strategy, provider engagement and client services. His experience at Optum also includes providing consulting services for payers and providers as senior consultant supporting the Risk Adjustment practice area at Optum Advisory services. Prior to Optum, Jeff held senior management roles at a Medicaid Managed plan in NYC.
In addition, Jeff also brings strong experience in vendor management and oversight as well as creating synergies and identifying points of integration across health plan and provider teams including Risk Adjustment, Quality, and Network Management.
Jeff received his MBA from the University of Connecticut and a Master’s degree from Boston University.
After a career in various roles related to analytics and process improvement, I’ve had the honor to serve as Director of Utilization Management and Risk Adjustment Solutions at Health Alliance for the last year.
Dawn Peterson is the Director of Risk Adjustment operations for Martin’s Point Health Care. Dawn has sixteen years of service on the business side of medicine within integrated health systems across the Nation. Professional positions Dawn has served in are various and in the fields of communication, auditing, education, billing and coding and leadership for professional fee for service, risk adjustment, care and utilization management, population health and HEDIS chart retrieval and review.
Tim Plank is the Director of Government Revenue for UPMC Health Plan in Pittsburgh, Pennsylvania. Tim has fifteen years of experience working in healthcare finance and operations, nine of those years being in Medicare Advantage Risk Adjustment. In his current role, Tim is responsible for Medicare Encounter Data Submission, RAPS Data Submission, monitoring and reviewing EDGE Data Submission, and Risk Adjustment Analytics for Medicare and ACA lines of business. A key role involves reviewing and reconciling data from both RAPS and Encounter Data to ensure accurate submissions as well as maximum revenue potential.
Shelley has more than 33 years of healthcare experience, including leadership positions in strategic and tactical planning, compliance, ACOs, Medicare, Medicaid, DSNP, MMP, organizational and workflow design, and CMS program auditing. She has guided health plans new to Medicare Advantage through application to fully compliant launches, and has helped MA plans achieve 4.5-5 Star ratings and accreditations with NCAQ, URAC, and AAAHC. Shelley has extensive experience in how to achieve compliance, earn high-quality ratings, and realize desired revenue in the Medicare Advantage space.
Brandon Solomon is Vice President and co-leader of Pareto’s Client Advisory
and Business Development teams. He is responsible for contributing to the
strategic growth of the organization, both through setting and pursuing
Pareto’s business development strategy, as well as ensuring our clients
receive optimal value from our solutions and services. Brandon and his
team support clients with robust analytics and technology solutions to set
strategic direction, uncover actionable areas for improvement and achieve
Brandon has been with Pareto since its inception, and before that, worked with health plan and provider organizations to solve their strategic, financial, operational and compliance challenges at Pareto’s sister company, HealthScape Advisors. He has deep expertise in regulated markets (e.g., MA, ACA, Medicaid) and has designed, implemented and run over a dozen operational divisions for health plans operating in these lines of business. Brandon’s advisory work has led to the identification, development and advancement of multiple Pareto solutions and capabilities to date, including continued expansion into the risk-bearing provider through solutions to achieve complete and accurate revenue capture.
Brandon is a frequent speaker at industry events, including RISE conferences, and has been published in HFMA’s magazine and Bloomberg. He earned his bachelor’s degree in economics from Indiana University.
Dr. Adele Towers
Dr. Towers is the Director of Risk Adjustment for UPMC Enterprises,
and is also a geriatrician on the faculty at the University of Pittsburgh.
At 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 and Clinical Analytics at multiple regional and national conferences.
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's team has consistently delivered market-leading performance and forward-thinking engagement with providers and members.
Mr. Weisbrod currently serves as the Vice President – Risk Adjustment at Network Health in Menasha,
WI. Mr. Weisbrod brings over 20 years of health insurance, healthcare analytic and human service
experience to Network Health. Mr. Weisbrod specializes in government programs, health plan
operations, risk adjustment and data analytics. Prior to his work at Network Health, Mr. Weisbrod
served as Director of Government Programs for a regional Wisconsin health plan serving the state’s
Medicare, Medicaid and Marketplace participants. Mr. Weisbrod previously served as the Director of
Operations for the Wisconsin Health Insurance Risk-Sharing Plan (HIRSP), the state’s high-risk insurance
plan. HIRSP also administered the federal high-risk insurance plan in Wisconsin prior to the
implementation of the Affordable Care act.
Mr. Weisbrod has taught part-time at the college level for over 11 years and has extensive experience training health insurance and human service professionals. Josh lives in Neenah, WI with his wife and three school aged children.
Michael has over 20 years of Healthcare experience w/ 9 years in risk adjustment with an emphasis on Medicare Advantage. Experience has ranged from managing RAF coding production, estimating risk adjusted financial accruals, managing vendor relationships, RAPs and EDS processes, In home assessments, and other prospective CDI programs. Have spent the past two years as the Director of Risk Adjustment and Quality for AdventHealth. Current role leverages prior health plan experience to educate AdventHealth providers on the importance of risk adjustment and coding to the highest level of specificity.