Results driven operations leader with over 15 years of hands-on experience contributing to better corporate performance by building effective teams, solving complex problems, improving processes and skillfully aligning resources with corporate objectives. Experience in healthcare claims processing and customer service. Successful in managing multiple tasks with strong analytical, problem solving and follow-through skills. Demonstrated ability to manage, motivate and build cohesive teams that achieve. Well-developed professional relationships with external and internal customers. Experience in TRICARE, Medicare Advantage and provider data management.
New Business Development
New Business Development
Contract Start-ups and Transitions
Contract Start-ups and
MS Word, Excel & PowerPoint
MS Word, Excel & PowerPoint Microsoft Word, Excel, PowerPoint, Access
Strong understanding of the need for confidentiality
Knowledge of office equipment (copier/fax) MS Word, Excel & PowerPoint
Quality Assurance Manager02/2014 to 06/2015BlueCross BlueShield of South CarolinaFlorence, SC
Oversee quality audits to ensure compliance with operating procedures and TRICARE program requirements including the Code of Federal Regulations and development of quality control processes. Manage 20 employees responsible for quality control activities to provide accurate and timely data in assessing operations performance.
Collaborate with operational management in other functional departments to support quality improvement initiatives, training, development of auditing protocols/criteria.
Facilitate the development of corrective and preventive action plans Prepare reports and analysis of quality data and impact on organization.
Monitor reports, quality processes, resources and improvement plans to ensure maximum efficiency, effectiveness and consistency are achieved in all assigned work areas/functions and that customer requirements are met Interview, hire and maintain adequate staff to respond to all business requirements.
Manage employee performance to ensure productivity, quality and timeless standards are met.
Manage employee/human resource issues and handle disciplinary action quickly and professionally Provide input, influence and partnership to develop training initiatives with regards to on-going quality performance data and error trends.
Initiate and support process improvement initiatives Monitor departmental budget.
Manage project management activities that include development of project schedules, cost estimates, resource allocations, specifications and project reporting Assist in development of quality assurance plans for new business contracts and proposals.
Create and deliver highly effective quality assurance presentations for management and partners.
07/1992 to 11/2012BlueCross BlueShield of South CarolinaFlorence, SC
Claims Operations Director01/2006 to 01/2012
Directed daily operation of claims processing and customer service related functions.
Developed and executed strategic and operational business plans for the department.
Directed and managed 125-150 exempt and non-exempt employees.
Developed operations management by establishing performance objectives and developing plans designed to strengthen management skills.
Reviewed and analyzed business and contract directives to assure a clear understanding of the requirements.
Ensured compliance with all applicable laws, regulations and contract requirements while meeting performance expectations through the establishment and implementation of effective management controls.
Implemented changes in an effective and accurate manner.
Successfully led contract start-up and phase out activities for multiple lines of business.
Participated in the benchmark test for new contracts.
Responded to requests for proposals and developed winning technical proposals for government programs.
Evaluated responses from subject matter experts to ensure compliance with requirements and to mitigate proposal risk.
Managed budget to maintain high quality and cost effective processes to meet business requirements.
Operations Manager01/2000 to 01/2006
Managed claims processing associates to ensure claims were processed in a timely and efficient manner while meeting contract compliance standards.
Prepared and analyzed claims processing reports and quality audits that measured the team's performance.
Administered and oversaw quality control procedures to ensure compliance of all corporate and contract requirements.
Identified potential education and system issues and then implemented training initiatives and system changes.
Established and maintained excellent customer service with internal and external customers.
Managed customer service associates to ensure that all correspondence and telephone inquiries were processed in a timely and efficient manner.
Participated as project leader on policy changes, quality improvement initiatives and system change efforts while ensuring corporate, contractor, and department policies and procedures were administered timely, consistently and accurately.
Identified and initiated change request and served as customer project lead to ensure accurate and timely implementation.
Assisted in budget preparation and monitored expenses related to the budget.
Provided the business requirements for the design of a multi-million dollar website that provided self-service for members and providers.
B.S: Biology1997Francis Marion UniversityFlorence, SCBiology
auditing, budget preparation, budget, business plans, contracts, excellent customer service, customer service, data entry, detail oriented, fax, functional, government, human resource, Team Building, management skills, Access, Excel, PowerPoint, MS Word, Microsoft Word, New Business Development, office equipment, Operations Management, Strong organizational skills, copier, policies, presentations, processes, Process Improvement, project lead, project leader, project management, proposals, proposal, protocols, quality, quality assurance, quality improvement, quality control, reporting, strategic, Strategic Planning, telephone, website