HEALTHCARE BENEFITS | CUSTOMER SERVICE | MEMBER SERVICES | COMPLIANCE MANAGEMENT Distinguished Healthcare Leader offering extensive experience in regulatory and operational leadership. Recognized for delivering strategic insight and transforming CORE COMPETENCIES operations, processes and procedures into first class services, ensuring exemplary levels of quality assurance and customer experience. Proven capacity to drive high-quality Service Operations service, achieving service standards by a cultivating collaborative, positive and motivational working environment, fostering high-performance teamwork. Call Center Operations Quality Customer Service: Proven track record in leading, building and Health Plan Operations mentoring high-performance customer service teams, engaging with them to cultivate joint ownership of the customer experience. Customer Experience Compliance and Quality Management: Played a key leadership role in Continuous Improvement securing of CMS five-star rating for 3 consecutive years by establishing tools Strategic Planning and mechanisms to monitor CMS compliance, identifying gaps and formulating resolutions. Team Development Cross-functional Leadership: Demonstrated capacity to work collaboratively Team Recognition with multiple departments to define strategies and initiatives that improve Performance Optimization efficiencies. Policy Development
Microsoft Word, Excel, PowerPoint, Outlook
DIRECTOR OF OPERATIONS TUKWILA, WAGROUP HEALTH COOPERATIVE/Sep 2013 to Current
Gained promotion to provide astute leadership, overseeing, developing and enhancing Health Plan Operations across Medicare Advantage Claims, Customer Service, and Enrollment, together with Member Appeals and Grievances for all lines of business.
Oversee a team of 9 direct-reports, coordinating operational activities, quality management, and compliance, consistently delivering high levels of efficiency and customer service while consistently achieving and surpassing business goals.
Customer Service functional leader for all lines of business, ensuring multiple call centers are sharing and utilizing best practice.
Created and conducted quality performance checks for all Medicare Member Services staff involved in enrollment activities to identify strengths and opportunities for training, and analyzing and reporting trends to executive leadership.
Transformed Customer Service Telephone Service, creating and executing strategies and procedures that significantly improved call quality and aligned management including consistently meeting call center metrics.
Managed operational compliance requirements, establishing and directing structures including overseeing annual training, monitoring and evaluating operations to ensure full compliance with regulatory and contractual requirements.
Directed Quality Assurance and Compliance including working collaboratively with Compliance Consultants on monitoring goals, identifying gaps and formulating strategies for efficient resolution.
Successfully reduced volume of appeals by 10%, by formulating effective 'pay and educate' strategies and increased partnerships with Appeals and Customer Service teams.
Played an integral role in reducing MA member complaints, contributing to root cause analysis and formulation of strategies to address areas of concern.
MANAGER BENEFIT & COVERAGE / CENTRALIZED TRAINING & DOCUMENTATION TUKWILA, WAGROUP HEALTH COOPERATIVE/Apr 2012 to Sep 2013
Led a team of 30 comprised of 20 Benefits and 10 Training and Documentation Associates.
Oversaw all aspects, process and.
procedural implementation and alignment with company and regulatory policies and standards.
Held responsibility for ensuring efficiency in form filing with Insurance Commissioner's Office in Washington and Idaho as well as accurate, compliant and timely submissions of Evidence of Coverage to CMS for Medicare members.
Established a single point of truth library and maintenance plan for health plan documentation housing all health plan policies, procedures and job aids.
Devised, implemented and maintained effective Medicare and Commercial coverage policies and benefit decision process.
Managed and guided the Annual Medicare Mailing Process Team, including managing CMS annual member mailing and collaboration with cross-functional team of internal customers.
Chaired Medicare and Commercial benefits committees, providing leadership to the evaluation and approval process for member benefits.
Successfully led Health Benefits Exchange plan filing, gaining recognition from Washington's Insurance Commissioner and internal leadership for outstanding work and received HPA Team of the Quarter Trophy.
MANAGER CONTRACT COMPLIANCE SEATTLE, WAGROUP HEALTH COOPERATIVE/Mar 2007 to Mar 2012
Efficiently managed development of comprehensive training curriculum including annual benefit implementation for all.
lines of business.
Proficiently managed and monitored Medicare and Commercial contract documentation and benefit.
policies to ensure full compliance with regulatory requirements.
Successfully reinstated Medical Coverage University for online and in-person benefits training for health plan and delivery system staff.
Garnered recognition from colleagues and members for the skillful reformatting.
benefit booklet for members and internal customers.
Accurately and efficiently reported non-covered Medicare codes to Medicare Finance.
Worked collaboratively with Sales to articulate and explain benefits and support benefit negotiations in meetings with key employer groups.
SEATTLE, WAGROUP HEALTH COOPERATIVE COORDINATOR MEDICAL COVERAGE COMPLIANCE & TRAINING/Apr 2003 to Apr 2007
Master of Business AdministrationUniversity of Phoenix2009Tacoma, WA
Bachelor of Arts: Communications & Public RelationsCentral Washington University2001Ellensburg, WACommunications & Public Relations