Operation Improvement Manager Resume Example Universal American Corporation

OPERATION IMPROVEMENT MANAGER

Summary

Qualified Customer Service Manager offering a record of successful job performance, proven problem solving ability and experience developing and implementing innovative solutions. Innovative Customer Service Manager who effectively executes process changes to improve operational efficiency.

Skills

Very Proficient in the following applications: Microsoft Word, Microsoft Excel, Microsoft Internet, Microsoft Outlook, EzCap, Facets, Macess, Clinical Coding Expert, Pegasus Encoder Pro- Ingenix, HIMS, QStar, Image Onsite, Avaya CMS, Nice, Medi Span, Calabrio, Virtual Credentialing, Cisco Web view and SharePoint.

Experience

Operation Improvement Manager
April 2011 to CurrentUniversal American Corporation － Houston, Texas

Create training manuals targeted at resolving customer issues.
Provide detailed monthly departmental reports and updates to senior management.
Resolve customer questions, issues and complaints.
Develop and implement policies, procedures and process improvement initiatives to improve retention rates and increase customer satisfaction.
Recommend changes to existing methods to increase the accuracy, efficiency and responsiveness of the customer service department.
Implement recommendations for improvement.
Conduct ongoing analysis of CTMs for continuous process improvements, improved efficiency and improved customer satisfaction.
Support quarterly physician meetings and resolve customer service issues identified by providers and their offices.
Support CMS audits Support off-site member retention and sales event meetings.

Call Center & Claims Research & Resolution Manag
March 2010 to April 2011Universal American Corporation － Houston, Texas

Responsible for the professional and performance development of staff Review/create departmental policies and procedures to assess compliance with functional and operational requirements.
Responsible for monthly budget adherence.
Responsible for supervising and evaluating work flow and call volume.
Ensure department staff is appropriately trained and quality assurance goals are achieved.
Ensure adherence to Centers for Medicare and Medicaid CMS requirements, guidelines and standards.
Conduct monthly monitoring and auditing activities to identify and assesses areas of compliance risk and recommend opportunities for improvement.
Monitors team performance trends and coach staff to ensure adherence to policy, procedure, and the highest level of customer service.
Responsible for performance of all lines of business (PFFS, PPO and HMO) Responsible for meeting and exceeding monthly goals.
Responsible for reviewing all training materials for both Resolution and Retention units.
Responsible for tracking CSR productivity via daily, weekly and monthly productivity reports.

Call Center & Claims Research & Resolution Supervisor
March 2002 to March 2010Universal American Corporation － Houston, Texas

Supervise HMO Call Center of 10 CSR's that consists of verification of eligibility, benefits, claims, authorization and appeal status to effectively implement specific client goals that develop an excellent rapport with clients.
Supervise Research & Resolution Call Center of 5 CSR's that consist of escalated calls, irate providers and provide images of cashed checks to the providers.
Run daily call stat reports for all Call Center skills on ACD calls, average talk time, abandonment rate, aux time, staffed time.
Perform Quality Assurance on CSR calls, provide feed back and coach as needed.
Incentive Program to recognize employees that go above and beyond on calls that score 100%.
Perform detailed reviews and analysis of support efforts including the implementation of process changes and other trends which improve client service levels and simultaneously, eliminating the possibility of penalties assessed by the client for under performance of call center performance goals.
Process claim payments in a timely manner and in accordance with contract terms which are specific to each provider resulting in overall increase in team productivity for Medicare, PFFS, PPO & HMO.
Review certificate of medical necessity for ambulance claims.
Utilized claim system to process claims, write up findings and actions taken to correctly adjudicate insurance claims.
Perform comprehensive research related to the facts and circumstances of a complaint, grievance, or appeal received and responsible for appropriate resolution to the appeal/ grievance in accordance with CMS guidelines.
Review certificate of medical necessity for ambulance claims.
Utilized claim system to process claims, write up findings and actions taken to correctly adjudicate insurance claims.
Perform comprehensive research related to the facts and circumstances of a complaint, grievance, or appeal received and responsible for appropriate resolution to the appeal/ grievance in accordance with CMS guidelines.

Medical Assistant
February 2001 to March 2002Ramon Pineda, MD － Pasadena, Texas

Check patient vital signs, draw blood, vaccinate, assist physician with in office procedures and perform radiology x-rays.
Prepare lab specimens to send out to Labcorp and Quest Laboratory.
Contact patient to schedule an appointment for lab results.

Education

Certified Medical Assistant : 2005National Institute of Technology － Houston, TX

High School Diploma : 2001Willowridge High School － Missouri City, Texas

Professional Development

Universal American Corporation- Lean Sigma Yellow Belt

Resume Overview

Companies Worked For:

Universal American Corporation
Ramon Pineda, MD

School Attended

National Institute of Technology
Willowridge High School

Job Titles Held:

Operation Improvement Manager
Call Center & Claims Research & Resolution Manag
Call Center & Claims Research & Resolution Supervisor
Medical Assistant

Degrees

Certified Medical Assistant : 2005
High School Diploma : 2001

Operation Improvement Manager Resume Example

Resume Score: 100%

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