Manager Quality Assurance And Reporting Process Resume Example

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Jessica Claire
  • Montgomery Street, San Francisco, CA 94105
  • Home: (555) 432-1000
  • Cell:
Professional Summary
Highly motivated Sales Associate with extensive customer service and sales experience. Outgoing sales professional with track record of driving increased sales, improving buying experience and elevating company profile with target market.
Skill Highlights
  • Leadership: Demonstrated excellence in transferring corporate visions into actionable tasks which require self-discipline, integrity and focus while taking personal responsibility for specific assignments and facilitating the collaborative works of others. * Interpersonal Communication and Relationship Management: Facilitates cross-departmental, inter-divisional, and inter-enterprise relations amongst internal & external resources. * Budget Management: Develops departments' budgets according to corporate guidelines and manages to meet goals within those financial constraints. * Staff Management: Facilitates subordinates' job enrichment and professional development objectives while ensuring they meet or exceed job requirements. Areas of Expertise
  • Multi-Site Healthcare Operations
  • Strategic and Operational Planning
  • Quality and Performance Improvement
  • Budgeting and Financial Reporting
  • Conducting Needs Assessments
  • Relationship and Team Building
  • Decision-Making and Problem Solving
  • Presentations and Contract Negotiation Removing Survey Deficiencies
  • Managed Regulatory Requirements
  • Recognized for providing visionary leadership that draws upon knowledge of multifaceted aspects of healthcare business
  • Integral partner with the planning and creation of the Provider Unit in the Grievance & Appeal Department
  • Successfully reorganized the Grievance and Appeal Department into several units to improve efficiencies reduce administrative expense and increase productivity
  • Budget preparation for over 6 millions dollars for all administrative and staffing expenses for two departments
  • Ensured all departmental goals are met at 99
  • Built a top-performing team of healthcare professionals
  • Implemented state-of-the-art imaging platform to boost operational efficiencies, reporting accuracies, and staff
  • Implemented a claims systems initiative targeted at responding to and resolving production problems to decrease the number of denial letters generated to our members
  • Developed and maintained strong effective relationships engendering respect and commitment with corporate colleagues, contracted providers and vendors, regulatory agencies and employer groups
  • Semone Morgan
Professional Experience
Manager- Quality Assurance and Reporting Process, 08/2010 to Current
Apex SystemsWest Des Moines, IA,
New York, NY 8/10 - Present EmblemHealth, Inc., through its companies Group Health Incorporated (GHI) and HIP Health Plan of New York (HIP) provides affordable, quality health care coverage and administrative services to approximately 3.4 million people. Manager- Quality Assurance and Reporting Process Improve or streamline the Grievance and Appeal Reporting and Quality Assurance process. Work closely with the Quality Specialists to ensure that the files that are being audited are accurate and timely. Manage the development and implementation of the Softheon Workflow System, ensuring departmental and corporate goals are met regarding receipt, scanning and processing of all correspondence received. Ensure staff reports statistical data are delivered in an accurate and timely manner. Work as an integral part of the ESAWS implementation projects, including writing the test case scenarios, testing the functionality of the system and documenting the defects in the UAT environment. Create and distribute the monthly, quarterly and annual reports that are distributed to various reporting agencies both internal and external. Gather & analyze the data needed for the monthly Medicare (STARS) & Commercial KBI reports, Quarterly Customer Satisfaction Improvement Committee (CESIC) reports, and other Monthly and adhoc reports as needed. Analyze and validate all Quarterly CMS/HPMS submittals. Liaise between vendors and end users for various applications. Work on several projects with external entities including Provider Relations, Care Management, and Customer Services to improve the overall customer experiences for EmblemHealth members and reduce the grievance and appeals submission. Ensure departmental compliance is reported accurately. Ensure files are printed and provided for quality audits internally and externally. Ensure all quarterly, regulatory and annual reports are completed prior to the scheduled executive meetings; maintain the accuracy of all reports distributed both within the department and externally. Ensure the system applications are functioning appropriately and enhancements are implemented for process improvements. Administrator for various systems applications which includes the C-MORE system, which is EmblemHealth's content Management sysstem. Conduct quarterly performance evaluations of the staff. Conduct training for all staff on a continuous basis. Assist with the budget preparation of over 6 million dollars for the Grievance and Appeals Department.
Claims Business Analyst, 11/2009 to 08/2010
, ,
Responsibility included review of and revisions of the Business Requirements for the proposed implementations in the Claims Department. Drafted and executed comprehensive test scenarios designed to validate the modifications to existing systems and procedures to yield the anticipated results. Executed the testing of individual projects which included, development of test scenarios, recording and reporting of test results, and conducting post implementation monitoring. Interacted with IS and other departments through the design, testing and execution of the implementation of new projects. Identified and communicated issues/problems to the Manager and testing team relating to testing and test outcomes that affect the project deliverables. Complete assigned task for each assigned test project on time accurately. Responded to and resolved production problems with implemented systems logic and organizational claims procedures. Participated in developing project plans for assigned testing projects. Served as the liaison with the Senior Analysts and Managers in Claims Operations concerning the business requirements, planning, testing and communication of projects. Conducted continuous post-implementation monitoring and provided continuous follow-up support to the Claims Department and other business partners. Maintained the test file documentation of all enhancements to existing systems and procedures.
Assistant Administrator, 03/2007 to 11/2009
ArchcareMontgomery, AL,
Decatur, GA 03/07- 11/09 Rem-Kiks Healthcare Services is a group of companies that provided Homecare Services, Adult Day Health services and transportation services to the disabled and elderly. Assistant Administrator Administrator of company-wide quality management and performance improvement initiatives in the areas of Utilization Review; Risk and Quality Management; Performance Improvement; and Social Services. Recruited and developed a 100-person staff representing a 40% increase. Implemented training programs that achieved a 95% staff retention rate in the first year. Coordinate a major business expansion to include a 200 member Adult Day health facility. Quality Assurance responsibilities included the development of the Total Quality Management System, overseeing the auditing of the company's processes with a concentration on customer satisfaction and the Corrective Action System. Provided timely data analysis and presentation to upper management regarding process improvement and reengineering plans. Provided quarterly reports on problem areas to senior and executive management. Oversight for recruiting and hiring Registered Nurse (RN), Licensed Practical Nurse (LPN), and Certified Nursing Assistant (CNA). Facilitated in excess of 30 in-serving training and Certified Nursing Aide (CNA) education programs to ensure a competent medical workforce and a compliant organization. Significantly reduced clients' discharge rate and cost expenditures resulting in steady revenue climb. Coordinated workforce management objectives with a focus on individual, departmental and company-wide initiatives and team concepts. Directed all areas of regulatory compliance and medical staff credentialing requirements. Managed the process of root cause analysis to identify, track and resolve adverse events encompassing the development, implementation and monitoring of a corrective action plans. Responsible for all aspects of the company's payroll processing function, while maintaining over 300 timesheets per biweekly pay period.
Assistant Director, 01/1998 to 06/2006
Department Of Veterans AffairsCity, STATE,
New York, NY 01/98 - 6/06 HIP Health Plan of New York (HIP) provides affordable, quality health care coverage and administrative services to approximately 1 million people Assistant Director Provided daily oversight of all aspects of business pertaining to the processing and regulatory compliance of member and provider written correspondence, complaints, grievances and Medicare appeals, including policy/procedure development, business strategies, staff recruitment/training, and budgeting/fiscal management. Implemented processes reflective of new federal, state, local and other regulatory agencies, such as NCQA in regards to the processing of member and provider written correspondence, complaints, grievances and Medicare appeals. Supervised a team consisting of Managers, Grievance and Appeal Analysts, and Administrative staff. Analyzed (statistical and qualitative) grievance and appeals data for the development of reports. Integrated department services into the organization's strategic mission by setting goals that aligned with the organization mission and monitoring progress toward goals. Worked closely with Senior Management in the development of short and long-term business strategic plans within the Grievance and Appeal Department. Monitored and prepared detailed reports and results for management. Evaluated reporting tools and performance measurements and made continuous improvements as needed. Ensured appropriate staffing to support departmental needs. Promoted employee satisfaction and implemented actions to maintain a productive and motivated staff. Manager Established and managed the operations and strategic direction of the Provider Grievance and Appeals unit, which responded to complaints, retrospective utilization reviews, claims adjudication requests and correspondence in a timely and efficient manner. Spear-headed the training and development of all Provider Grievance Analysts, located both in New York and Florida. Developed and implemented policies and procedures to ensure timely, appropriate, and efficient handling of member and provider grievances and appeals in accordance with state and federal regulations, NCQA, and other regulatory requirements. Responsible for the exceeding the compliance rates of 98% for the timely response of grievances and appeals, and claim prompt pay guidelines as required by state and federal regulations. Managed the Medicare Grievance and Appeal process. Accountable for all performance and implement actions as warranted. Reviewed and responded to all federal agencies' cases and appeal hearing requests. Worked closely with the VP of Human Resources to implement a successful departmental wide program targeted to improve the employee morale and reduce the department's employee turnover rate. Ensured that staff reviews grievance files in a timely manner and that appropriate processes are applied. Project management responsibilities included the coordination of interdepartmental communications including Claims, Accounting and Enrollment. Ensured that pertinent updates regarding policies and procedures are disseminated to the staff. Directed staff to ensure that all standards of operations are maintained at all times. Identified and implemented opportunities to address root causes of issue with departments, Delegated Entities, Medical Groups, and Providers. Appeals Coordinator Within stringent timeframes investigated member and provider complaints regarding various issues from contractual and payment disputes to general complaints about the nature and quality of services rendered. On a daily basis, monitored a caseloads while consistently meeting deadlines for resolution. Prepared and submitted cases to the Independent Review Entity (IRE) as required. Effectively interacted with internal and external entities to obtain information within the required time.
Education and Training
B.S.: Health Administration / Public Administration, Expected in
Long Island University / C.W. Post Brookville - Brookville, NY
May 1997 Long Island University / C.W. Post Brookville, NY * B.S., Health Administration / Public Administration.
M.S.: Human Resource Management, Expected in
Mercy College Dobbs Ferry - Dobbs Ferry, NY
December 2011 Mercy College Dobbs Ferry, NY * M.S., Human Resource Management. Computers Proficient in Windows Word, Excel, PowerPoint, Outlook, and Departmental Web based system. CSS/SAWS (Customer Service/ Satisfaction Assurance Workflow System) are EmblemHealth Plan Integrated Enterprise System. Hyperion Planning- Budget Application. Q-Care system-database that provides the Emblem Health Plan with a unified system to handle the organization's core processes, such as Enrollment and Claims & MaxMC systems.
Registered Nurse RN Nursing Assistant CNA
Decision-Making and Problem Solving Presentations and Contract Negotiation
Satisfaction, Training, Basis, Correspondence, Medicare, Million, Regulatory Compliance, Claims, Operations, Accountable For, Accounting, Assistant Director, Budgeting, Cases, Federal Regulations, Human Resources, Progress, Project Management, Recruitment, Reporting Tools, Staffing, Strategic Direction, Quality Assurance, Testing, Budget, Workflow, Audits, Budget Preparation, C-more, Cms, Content Management, Content Management System, Documenting, Its, Process Improvements, Scanning, Test Case, Uat, Auditing, Automated Payroll, Certified Nursing Assistant, Clients, Cna, Corrective Action, Corrective Action Plans, Data Analysis, Increase, Lpn, Marketing Analysis, Nursing Assistant, Payroll, Payroll Processing, Process Improvement, Recruiting, Registered Nurse, Rn, Root Cause Analysis, Social Services, Total Quality Management, Training Programs, Utilization Review, Business Requirements, Documentation, File, Liaison, Project Plans, Budget Management, Budgets, Contract Negotiation, Exceed, Financial Reporting, Healthcare, Healthcare Operations, Imaging, Problem Solving, Relationship Management, Team Building, Css, Customer Service, Database, Excel, Human Resource Management, Hyperion, Outlook, Powerpoint, Receptionist, Retail Sales, Web Based, Word

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Resume Overview

School Attended
  • Long Island University / C.W. Post Brookville
  • Mercy College Dobbs Ferry
Job Titles Held:
  • Manager- Quality Assurance and Reporting Process
  • Claims Business Analyst
  • Assistant Administrator
  • Assistant Director
  • B.S.
  • M.S.

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