It Quality Assurance Lead Resume Example

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(555) 432-1000,
Montgomery Street, San Francisco, CA 94105
Executive Summary

Experienced manager with over fifteen years of expertise and results in medical health insurance operations who possesses an intimate knowledge of internal business processes and health insurance industry. Extensive knowledge in business operations including processing, systems testing, project management fundamentals, electronic submission, provider networks, TPA implementation and vendor management. Success through team building, mentoring, diversity and retention.

Core Qualifications
  • Analytical
  • Policy Interpretation
  • Operations management
  • Supervision and training
  • Calm under pressure

  • Microsoft Office
  • Amisys Advance super user
  • Macess EXP super user
  • Ultipro
Dade Community College Miami, FL Expected in 12/1998 Associate of Arts : Business - GPA :
Florida International University Miami, Florida Expected in Bachelor of Arts : Business Administration - GPA :
Other Training , Expected in : - GPA :
  • Completed the EDI Partners Mastering HIPAA EDI Implementation Guides in 2011.
  • Successfully completed AHIP AHM 250 for PAHM designation in 2009.
  • Completed training in Amisys Pricing/Benefits configuration, EXP configuration, management skills, Building Business Acumen, insurance terminology, Prompt Pay regulations, and Time Management.
Professional Experience
Amita Health - IT Quality Assurance Lead
Rochester, MI, 10/2014 - Current

Selected to lead the new IT Quality Assurance Team.Planned, scheduled and coordinated detailed testing of medium-scale and small projects.Recommended design modifications to eliminate system malfunctions.Coordinated contractors to deliver high quality projects within specified time frames.Created standards, methods, processes and procedures for testing system changes projects.

AvMed Health Plans - IT Lead System Analyst
City, STATE, 07/2012 - 10/2014

Managed team of 9 of IT professionals. Responsible for supervision, including determination of workload, delegation of assignments, training, monitoring, evaluating performance, and initiating corrective or disciplinary actions.

Accomplishments include:

  • Leading the support and maintenance of all major applications for the company including Amisys Advance, EXP Macess, and Acuity.
  • Leading different new ASO group implementations for IT.
  • Received special recognition for the support provided during a major implementation project for the Claims processing system (Amisys Advance Release 6.)

AvMed Health Plans - Claims Operations Manager
City, STATE, 10/2004 - 07/2012
  • Responsible for leading and managing the day-to-day operations of the assigned Claims Department functions to produce exemplary results to include Claims Adjudication, Coordination of Benefits, Overpayment Recovery, Quality Control, Claims Review and Provider Appeals.Researched new technologies and assessed feasibility for inclusion in new concepts.
  • Provide appropriate technical and managerial support ensuring key performance indicators mandated by state, federal and group and internal requirements are met.
  • Interacted and coordinated with clinical staff and Medical Directors to ensure appropriate case disposition and clinical decisions are being conducted.
  • Provide project leadership for ongoing configuration and software implementations, including, vendor selection, configuration, testing, table designs and code sets.
  • Accomplishments: Business Lead most of major projects for new claims processing systems and upgrades to successful implementations including the Amisys Advance upgrade in 2007, Paper to EDI delegation in 2011, and the EDI 5010 implementation in 2012.
  • Developed a strong understanding of insurance policies and legal issues through completion of AHIP's AHM 250 course.
  • Developed a better understanding of the X12 TR3 standards by completing an EDI Partners on-line two day education seminar.
  • Achieved excellent audit results in all regulatory and group audits.
  • Excellent ratings from direct reports, peers and superiors in the leadership competency assessments.
  • Led department with other manager while Director's position was vacant.
AvMed Health Plans - Claims Supervisor
City, STATE, 01/1 - 11/2015
  • Responsible to supervise and lead staff of claim examiners, claim reviewers and clerks.
  • Monitor workflow to ensure it follows departmental procedures and production standards.
  • Hire, train, develop and motivate staff to achieve optimal performance in a fast paced environment Assist claims manager and director with all phases of development, organization, planning and implementation of projects assigned to the department.
  • Accomplishments: Trained indexers, examiners and reviewers to meet and exceed departmental goals.
  • Participated as a super user and tester in the Member Number Conversion Project in 2006.
  • Participated as decision maker and tester in the conversion of all home-grown codes in 2004.

Multi-unit Operation Management

Problem Resolution

Decision Making

Interpersonal Skills

Process Improvement

Vendor Sourcing

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Resume Strength

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Resume Overview

School Attended
  • Dade Community College
  • Florida International University
  • Other Training
Job Titles Held:
  • IT Quality Assurance Lead
  • IT Lead System Analyst
  • Claims Operations Manager
  • Claims Supervisor
  • Associate of Arts
  • Bachelor of Arts

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