Detailed, goal-oriented health care professional with fifteen (15) years of managed care experience seeking an opportunity to utilize interpersonal and leadership skills, and strong knowledge base of regulatory standards and guidelines.
Strong oral and written communication skills
Attention to detail
Consistently meet goals
Strong interpersonal skills
Microsoft Office Suite
Health Insurance Specialist03/2013
to Current THE CENTERS FOR MEDICARE AND MEDICAID SERVICES
Assigned tasks to associates, staffed projects, tracked progress and updated managers, partners and clients as necessary.
Developed media kits.
Planned and executed events and marketing programs, producing five times target number of qualified leads.
Quality Improvement & Compliance Manager02/2009
to 03/2013 KAISER PERMANENTE – Rockville,
Responsible for the communication and auditing of all new regulatory mandates to the Member Services department.
Develop, implement, and manage training strategies to ensure that regulatory requirements are met.
Initiate formation of work teams to address communication and training strategies for departmental staff.
Manage process for ensuring that all staff is trained on Member Services regulatory requirements and departmental procedures.
Review all new legislation affecting Member Services.
Partner with managers and senior leaders to ensure that department needs are anticipated as part of this process and that organization is prepared to deal with any such changes.
Develop policies and procedures to ensure regulatory and departmental compliance.
Coordinate the review of such policies and procedures with internal departments (legal, compliance, quality) and regulatory agencies.
Ensure approval of policies and procedures is maintained with all required agencies.
Conduct organizational assessments to identify opportunities for future improvements in ability to serve members.
Lead quality improvement activities, including establishment of department goals, development of work plans, assessment of current performance and future needs, and project management to ensure that all department goals are met.
Manage departmental preparation for all audits of departmental activities including Member Services file review.
Interface with contracts, quality, compliance and any other departmental liaisons coordinating an audit.
Responsible for coordinating departmental presentations and supporting Documentation required as part of an audit.
Maintain tracking system which facilitates departmental readiness for anticipated audits.
Active participant on multiple projects and associated project teams that are cross functional and multidisciplinary for purposes of understanding organizational changes and designing compliance or quality improvement strategies for Member Services staff.
to 02/2009 KAISER PERMANENTE – Rockville,
Interview candidates for positions within the Appeals & Correspondence Department.
Facilitate the Appeals Committee on a weekly basis.
Train new employees on Medicare appeals process.
Review and edit outgoing correspondence to Health Plan members and regulatory agencies.
Perform audits of Commercial and Medicare Appeals.
Address Medicare Part D email concerns received via Medicare Health Plan Management System.
Research and address escalated member and regulatory agency concerns.
Review Desk Level Procedure and Policies & Procedure prior to distribution.
Participate on HPSA and Self-Funding projects.
Gather and compile data for presentation in the Quarterly Appeals Forum.
Triage requests for expedited appeals.
Assist members and health care providers with benefit questions and claims issues.
Medicare Appeals Analyst04/2002
to 10/2007 KAISER PERMANENTE – Rockville,
Research and address Medicare Appeals and Grievances in accordance with all Health Plan and regulatory requirements.
Processed Medicare Appeals and Grievances within the required NCQA and Medicare timeframes.
Prepare case for presentation to the Appeals Committee on a weekly basis.
Maintain MACESS database log.
Submit denials that are upheld by the Appeals Committee to the Center for Health Dispute and Resolution (CHDR).
Investigate inquiries from regulatory agencies.
Train new employees on Medicare appeals process.
Review and edit outgoing correspondence to Health Plan members.
Represent the Health Plan at Administrative Law Judge (ALJ) hearings, resulting in a favorable outcome.
Perform weekly audit of Commercial and Medicare Appeals.
Address 1-800 Medicare concerns received via Medicare Health Plan Management System - CTM.
Bachelor of Science: Business AdministrationCurrentUniversity of Maryland-University College-
Associate of Science: Business Administration 2009Prince George's Community College-
Administrative, agency, auditing, business processes, contracts, database, Department of Health, designing, direction, Documentation, edit, email, functional, Insurance, Law, legal, letters, Microsoft Access, Microsoft Excel, Office, Microsoft PowerPoint, Microsoft Word, NIS, organizational, Personnel Management, Policies, presentations, project management, quality, quality improvement, Research, strategic, Visio