A seasoned and highly-performing health care manager with a strong clinical, compliance and reimbursement background that included successes in organizational growth, turn-around, and performance improvement. Key strengths are leadership, problem-solving, analysis and communication,
Directs all aspects of Medical and Pharmacy Appeals for the entire HealthSpring organization, as well as the Part D Quality program, and appeals for the Medicaid programs of Texas STAR+Plus and Illinois MMA project. Monitor, analyze and prepare the annual department budget. Evaluate current procedures and practices for accomplishing the organizations and department's objectives and to ensure compliance with all related laws, regulations and company processes. Chair the Part D Quality Improvement Committee; serve on the Pharmacy & Therapeutics committee. Research and incorporate best practices into operations. Assures that department functions are coordinated with other operating departments. Responsible for the statistical analysis of and business reporting for appeal utilization data. Participates in NCQA accreditation of the plan.
Oversee the Part D appeals department and the Pharmacy Quality department. Established the Part D Quality program Manage Supervisory, professional (RN) and non professional staff. Facilitate and collaborate with cross functional teams to develop and implement focused quality improvement projects. Apply leadership strength and critical thinking effectively provide guidance to the quality improvement team on the best approach to mange quality initiatives and appeals processing. Coordinated, directs, and managed the activities of the appeals department. Responsible for the analysis of regulations and timeliness requirements of pharmacy appeals processing.
Oversee the processing of all member and provider appeals for the commercial, Medicare and Pharmacy line of business. Develop reporting to monitor and maintain denial notification and appeal processing in accordance to state and federal guidelines. Manage professional (RN) and non professional staff.
Responsible for all clinic activities related to quality of care, cost control, facility growth and compliance with federal and state standards. Acted as a mentor to a new nurse administrator. Managed professional (RN, LCSW, RD) and non professional staff.
Assisted in acquisition of initial two state Part B Medicare Contract and expansion of business to three additional states and Part A and Part B Medicare Contract for performance of Medicare Fraud Investigative work. Developed standard operating procedures, hired and developed multi disciplinary staff, developed and maintained relationships with appropriate law enforcement agencies. Established work metrics andeliminated investigative work back load inherited with contract award. Designed and implemented a medical records tracking and review system. Established work metrics and eliminated prepayment review backlog and untimely reviews while maintaining timely post payment reviews in support of the fraud investigative work. Managed supervisory, professional (RN, JD) and non professional staff.
Managed multidisciplinary staff of legal, paralegal, investigative and medical personnel responsible for development and referral of potential fraud cases to law enforcement for 3 state area. Developed, Implemented and Monitored Governmental budget request. Analyzed process for weakness and development of process improvements. Transitioned workload to PSC when workload transferred to other agency. Managed professional (RN, JD) and non professional staff.
Oversaw $6.5 million monthly revenue for seven state region. Implemented policies and practices to decrease days A/R. Developed Managed Care Contracts for seven state regions for third party payment. Performed financial analysis of clinic operations to establish needed contract rates. Managed non professional staff.
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