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Medicare Coordination Of Benefits Manager Resume Example

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Jessica Claire
Montgomery Street, San Francisco, CA 94105
Home: (555) 432-1000 - Cell: - resumesample@example.com - -
Professional Summary
Bringing 26+ years of Claims Processing, Claims Recovery for Medical and Pharmacy, Coordination of Benefits (COB),  Medicare Secondary Payer (MSP) experience, and Medicare & Medicaid regulatory and compliance.
Skills

o  project development and various stages of system testing, Unit, Product (System), Integrations, Regression, and User Acceptance Testing

o  Investigation and problem solving

o  Claims Adjustments, Audit, Editing, Projects and Initiatives, Reporting, Coordination of Benefits, Encounters and Production

o  Resolve CMS Grievance and Adjustment appeals and resolution process, including claims CMS CTM complaints.

o  Claims processing & recovery

o  CDAG&ODAG CMS claims auditing and departmental monitoring

o  Claims adjustments & retro recovery

o  Coordination of Benefits (COB), including State, Federal and Third Party Liabilities and COB regulations and guidelines

o  Quality Assurance (QA) internal auditing o  Microsoft Office application, (i.e. Access, PowerPoint, Excel, Visio & Microsoft word.)

o  Facets software application, IKA gateway, Pega application and other system.

o  ESRD MSP eligibility requirements

o  Enrollment OHI eligibility validation.

o  Enrollment reporting (MMSEA- SECT 111 Mandatory Reporting & COBA-CMS (Crossover claims) Reporting

o  ECRS submission (Flat File Creation & Web Flat File Submission)

o   Claims processing and COB claims processing

o   Claims audit, appeal and adjustment

o   MSP & Coordination of Benefits rules and guidelines

o   MSP Premium Adjustment process and recovery

o   Proficienct in  CMS compliance and regulatory in Claims, Enrollment and COB MSP Part C and Part D

o   Medicare Advantage and/or Medicare Prescription Drug Plans (MAPD/PDP) requirements

o   MA/MAPD/PDP Medicare claims recovery  (Medical & Pharmacy)

o   Proficient in all claims processing, MSP processing and claims appeal & grievances.

o   Manage Claims and MSP CMS Plan Organization and Financial Audits.

o   Initiate and manage cross-functional teams and multi-disciplinary projects

o   CMS guidelines, Federal Regulations, CMS Audits guidelines, CMS Enrollment, MSP & Claims Manual requirements and CMS chapters (MSP/Claims Processing/CMS Compliance)

o   NCQA and HCFA guidelines Electronic Correspondence Referral System (ECRS) submission

o   design staff work processes, policies and procedures

o   staff training and supervision o   project planning management and delegate tasks

o   team improvements and staff development

o   Strong critical thinking, decision making and problem solving skills

o   manage day to day department operations

o   coaching, counseling and evaluation of employee’s performance

o   maintains and promotes organizational values

o   solving, investigation and critical thinking

o   establish and maintain positive and effective work environments

o   maintain and support required department production for quality, quantity and completion of work

o   Review and advise claims complexity and sensitivity issue

o   Recommend and assist FDR  acquisition of vendors and other tools or equipment, for optimize departmental resources and  performance and output

o   (SME)  Subject Matter Expert Government MSP, COB , CMS MSP Government Enrollment, Dual Eligibility & Claims process

Work History
2011 to Current
Medicare Coordination of Benefits Manager Foundation Capital Golden, CO,
    • Responsible for overseeing complex high-level claim review, and identifies areas of over-payment. 
    • Manage and oversees claim auditing processes and identify process improvement opportunities.
    • Oversees business partner claims processing and auditing and maintain the standards quality and accuracy including claims Fraud, Waste and Abuse monitoring.
    • Develop, secure approval of, and implement policies, procedures, and protocols necessary to achieve short and long-term goals and objectives for Government Enrollment & COB Department. 
    • Develop and establish data maintenance, MSP:  reconciliation, reporting, analysis, trending, project management.
    • Support reconciliation requirements for Medicare membership enrolled in a government program and provide a project management activity that is not limited to a sound and effective implementation of all system related interfaces, development of an infrastructure that support project initiatives, process workflows, relevant and meaningful data reporting analysis, and in addition to timely and accurate migration of system enhancements.
    • Manage, maintain, and ensure department enrollment group, individual, Medicare Application and COB processes. CMS Claims or COB Appeal and resolution process, including CMS CTM complaints and Clams Grievance.
    • Manage CMS regulation and MA/PDP Plan requirements for Medicare Secondary Payer (MSP) and provide support to Claims Division (CMS Claims guidelines & Enrollment guidelines).
    • Manage, maintain, and ensure compliance with departmental and corporate based upon the CMS guidelines.
    • Ensures compliance with all regulatory and accreditation standards and updates policies and procedures to reflect changes in regulatory requirements.
    • Manage Plan/CMS crossover claims and COB Agreement reporting, CMS MSP Demand Request, Claims Retro Active Recovery for Medical & Pharmacy.
    • Develop and establish data maintenance Government Enrollement: Plan File Processing Responsibilities DTRR (daily) CMS submission and monthly MARx reporting including disenrollment, Low Income Subsidy (LIS), Late Enrollment, and (PDP) Part D Plan enrollment; training and implementation of process.
    • Oversee the development and implementation of internal/external controls to ensure administrative cost-effectiveness, accurate and correct coverage determinations in support of CMS Part C, Part D and MSP regulations.
    • Manage day to day Medicare Advantage operational issues and facilitate resolution if applicable and provide staff with direction and guidance in making accurate determinations and addressing system or workflow concerns. 
    • Act as a Liaison between departments and  other external entity and CMS Government Agency.
    • Manages several subordinate employees in the assigned area(s). Responsible for the overall direction, coordination, and evaluation of the department. 
    • Encouraged creative thinking, problem solving, and empowerment as part of the facility management group to improve morale and teamwork.
    • Carries out menagerie responsibilities in accordance with the organization's policies and applicable laws. Responsible for but not limited to interviewing, hiring, and training employees. 
    • Department planning, assigning, and directing work.  Employee appraising performance, including mentoring, rewarding and disciplining employees.
    • Provide management support by addressing complaints and resolving problems. Establish department goals and objectives that support continuous quality improvement.
    • Develop and maintain department system monitor, measure, and performance report and achievement for long-term goals and strategic initiatives that has impact Claims & Enrollment Division.
    • Manage and maintain CMS Department MSP reporting for COB, including ECRS, SEC111 Mandatory Reporting and COBA (Crossover Claims) and data maintenance for PBM (Pharmacy), MSP OHI, Dual coverage and CMS reporting.
    • Manage and responsible for the design, development, and system testing for any software upgrades & implementation, including testing with external vendors.


07/2010 to 2011
Lead Medicare Liaison Health Alliance Plan (HAP) City, STATE,
  • Manage CMS regulation and MA/PDP Plan requirements and represents the COB Department.
  • Knowledgeable of managed care contractual and regulatory requirements for Medicare.
  • Support COB CMS MSP audits and provide written audit report of finding, recommendations to management and Compliance committee.
  • Research Medicare regulations and MA/PDP plan requirements. 
  • Provide guidance and develop process flows, department procedures, and training material as needed to demonstrate compliance.
  • Monitor implementation and/or corrective action plans related to COB Department and serve as a resource to departments and health plans on compliance issues.
  • Assists with the coordination of external audits including management of documentation requests and site visit coordination. Directs communications with departments to ensure consistent understanding of contractual, state, and federal regulatory requirements that affected COB Department.
  • Assists and supports compliance-related projects and initiatives, participating collaboratively in staff meetings, committees, projects and teams to resolve issues and meeting compliance program goals.
  • Assists COB Department with HIPAA regulation and responsibilities.
  • Ability to develop organizes, analyze, and implement procedures and review, analyze and interpret regulatory requirements in a clear and concise manner.
  • Clear and concise report writing and presentation skills and ability to work and communicate effectively with employees at all level.
  • Strong orientation to deadlines and details with ability to meet competing deadlines. Manage HAP’s COB data collection for Commercial, Medicare Advantage (MA) and PDP products. 
  • Manage workflow activities and core functions within the COB Department.  Develop and maintain production mining inventory and reports to manage COB activities such as: error report processing, discovery related activities, inquiry process, recovery process, and production reports, departmental QA error report, claims division accuracy, FMC monthly & quarterly report and data analysis.
  • Data maintenance, MSP reconciliation, reporting, analysis, trending, project management, CMS Audits and reconciliation requirements for Medicare membership enrolled in a government program.
  • Project management activities, but not limited to a sound and effective implementation of all system related interfaces, development of a infrastructure that support project initiatives, process workflows, relevant and meaningful data reporting and analysis, in addition to the timely and accurate migration of system enhancements. 
  • Develop, maintain, and distribute weekly, monthly, quarterly reports and annual key performance indicators for external entity.
  • Identify issues as a result of reviewing and analyzing data, and present improvement opportunities to the leadership for the purpose of providing immediate solutions.  Work in concert with Leadership to enhance the COB reports. 
  • Continued develop systematic and automated process for COB membership and solutions to increase overall effectiveness.
  • Support and organize COB Department and corporate initiatives that serve as an internal resource for education, training, and resolution of issues related to Medicare COB requirements including those associated with government programs.
  • Developed and created department procedures, training materials, and tracking reports, and facilitate the development and maintain a COB determination manual process and procedures. 
  • Manage Medicare Advantage operational issues and facilitate resolution and provide staff with direction and guidance.
  •  Act as a Liaison between COB Department, Claims Division, other HAP’s Department and CMS Governmental Agency.
  • Coordinate and track COB reporting, reconciliation, and recovery in effort to identify financial impact as it relates to premium dollars.
  • Coordinate system testing, enhance data information, and work with outside entity, providing CMS solid COB data management and analytical reporting.
  • Support the implementation of compliance and regulatory requirements through department procedures, workflow processes and work directly to MA Leadership.
  • Design ad hoc queries and reports and analyze COB, Membership and Group data as needed.  Devise, develop and produce routine reports to track and monitor COB statistics for Medicare membership.
  • Monitor and coordinate COB activities associated with Part D and MA membership.  Support the execution of plan requirements related to Medicare membership and other regulatory provisions.
  • Identify, investigate, and resolve related system and data management errors that impact COB data Support COB and MSP payment recovery activities including subrogation, premium reconciliation efforts, and administration of COB recovery efforts including vendor support. 
  • Use expertise in data management and analysis to track quality measures over time, identify opportunities for improvement, develop, and implement solutions.
  • Maintain and monitor monthly QA (Quality Review) Departmental process, reporting and procedures. Revises and develops audit tools to reflect current standards, contract changes, and regulations. Manage and support IT execution and development, design, testing, and implementation and work directly with HAP leadership to identify data trends and develop and implement process for improvements solutions.
05/2008 to 07/2010
Medicare COB Liaison Health Alliance Plan (HAP) City, STATE,
  • Manage HAP’s COB data collection for Commercial, Medicare Advantage (MA) and PDP products. 
  • Manage workflow activities and core functions within the COB Department. 
  • Develop and maintain production mining inventory and reports to manage COB activities such as: error report processing, discovery related activities, inquiry process, recovery process, and production reports, departmental QA error report, claims division accuracy, FMC monthly & quarterly report and data analysis.
  • Data maintenance, MSP reconciliation, reporting, analysis, trending, project management, CMS Audits and reconciliation requirements for Medicare membership enrolled in a government program.
  • Project management activities, but not limited to a sound and effective implementation of all system related interfaces, development of a infrastructure that support project initiatives, process workflows, relevant and meaningful data reporting and analysis, in addition to the timely and accurate migration of system enhancements. 
  • Develop, maintain, and distribute weekly, monthly, quarterly reports and annual key performance indicators for external entity. Identify issues as a result of reviewing and analyzing data, and present improvement opportunities to the leadership for the purpose of providing immediate solutions. 
  • Work in concert with Leadership to enhance the COB reports.  Continued develop systematic and automated process for COB membership and solutions to increase overall effectiveness. Support and organize COB Department and corporate initiatives that serve as an internal resource for education, training, and resolution of issues related to Medicare COB requirements including those associated with government programs.
  • Developed and created department procedures, training materials, and tracking reports, and facilitate the development and maintain a COB determination manual process and procedures. 
2002 to 05/2009
Quality Assurance Auditor Health Alliance Plan (HAP) City, STATE,
  • Reported internal control issues to management and supplied comprehensive recommendations to mitigate the associated risks.
  • Communicated audit results to upper management through written reports and oral presentations.
  • Gathered data for internal audits through interviews, financial research and downloads.
  • Created standard operating procedures.
  • Coordinated work between multiple departments.
  • Developed first-rate training programs.
  • Monitored employee work and developed improvement plans.
  • Precisely completed appropriate claims audits, documentation and process requirements
  • Reviewed and resolved claim issues captured in CLAIMS edits and claims error.
  • Meticulously identified and rectified inconsistencies, deficiencies and discrepancies in claims processing process.

2001 to 05/2002
Reviewer Specialist Health Alliance Plan (HAP) City, STATE,
  • Review and validate claims appeal and grievances.
  • Manage high appeal claims process and resolutions.
  • Manage day to day COB claims review based upon the CMS and ERISA/NAIC guidelines.
  • Respond to complaints, grievances and appeals  and the same time adhering to all regulatory, accreditation and internal processing timelines and guidelines.
  • Executes member appeals across multiple departments within the Plan and with representatives from external vendors.
  • Responsible for the preparation, research of data and records as well as all associated reports required to meet internal and external requirements. Ensures quality and organization of appeals documentation.

10/1998 to 2001
Senior Claims Appeal SelectCare, Inc., City, STATE,

Claims Processing & Appeal

Claims adjustment and recovery (COB)

Obtains information necessary to properly investigate and evaluate each case by corresponding with agents, insureds, claimants, witnesses and others

Monitors appropriate claim outcomes through self-audit process

May serve as a member of project teams, contributing to the achievement of project objectives.


Education
Expected in 2003 – 2005
Master of Arts: Liberal Arts in Social EconomicSocial Economics
Madonna University - Livonia Michigan,
GPA:
Expected in 1999 – 2003
Bachelor of Arts: Fine Arts and Management
Madonna University - Livonia Michigan,
GPA:
Expected in 1999 – 2003
Bachelor of Arts: Graphic Design
Madonna University - Livonia Michigan,
GPA:
Expected in 1990 – 1992
Associate of Applied Science: Medical Assistant
Andover College - Portland, Maine
GPA:

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Resume Overview

School Attended
  • Madonna University
  • Madonna University
  • Madonna University
  • Andover College
Job Titles Held:
  • Medicare Coordination of Benefits Manager
  • Lead Medicare Liaison
  • Medicare COB Liaison
  • Quality Assurance Auditor
  • Reviewer Specialist
  • Senior Claims Appeal
Degrees
  • Master of Arts
  • Bachelor of Arts
  • Bachelor of Arts
  • Associate of Applied Science

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