Rafael Loza

Background

About Rafael Loza

Profile – Health Care Leader with a unique combination of skills including project management, Medicaid/Medicare/Marketplace managed care compliance, case management and utilization management operations, NCQA accreditation, process improvement, performance management, medical and behavioral health integration, with experience in Government and Private Health Care delivery systems. Experience • Effective Health Care project management, including development and implementation of work plans and other project monitoring/tracking and accountability tools • Management and implementation of Medicaid/Medicare managed care compliance requirements in Medical Management (Utilization Management and Case Management) programs • Management and implementation of NCQA accreditation requirements in Medical Management (Utilization Management and Case Management) programs • Medicare/Medicaid Implementation of new programs - Case Management and Utilization Management readiness • Medical and Behavioral Health Integration project management • Medicaid/Medicare Marketing Guidelines management • Delegated Vendor Oversight - Medical Management operations and compliance risk mitigation • Program administration • Performance management • Data-driven strategic planning and program evaluation • Management of data collection and quality assurance • Management of policies and procedures, including implementation of new policies due to contract amendment changes or rule changes • Development of quality improvement initiatives • Meeting management and facilitation • Contract management Professional Goals • Contribute to efforts to achieve the "Triple Aim" and drive Return on Investment (ROI) • Continue growing leadership skills