Manager Quality Control

J OSANNE BLACKWELL

***** ** ** ****** #*-*** Sunrise, FL 33323 954-***-****

****************@***.***

SUMMARY

Highly accomplished individual with over fifteen years in the servicing of Health Care Claims and Provider

Service, Main focus is in the area of underpayment/overpayment validation and auditing of health

claims. Extensive knowledge of all insurance industry products, with a quantifiable history of success

in creating savings, identifying cost reductions, creating long-term customer relationships, and in the

coordination of claims and recovery activities to ensure prompt and accurate payments. Knowledge

includes:

• •

UAFC/TPA clients Recovery Effort Management

• •

COB and TPL Cost Avoidance Claims Adjustments

• •

Claim Workflow Analysis State/ Federal Compliance

• •

Quality/Standards Auditing Claim Liability Reporting/Analysis

• •

Staff Leadership and Training Procedures Standardization

• •

Sarbanes-Oxley Compliance Claims Appeal

CAREER HISTORY

BLACKMAPLE GROUP, Ft. Lauderdale, FL 2012-Date

VP of Operations

Report directly to the CAO. I am responsible for overseeing the day-to-day functions of the recovery

Operations, lending full support to the overall company’s business needs, including but not limited to the

loading and auditing of new contracts, and the validation of under-payments identified.

• Implementation process for new clients

• Manage client accounts

• Load/ QC facility contracts in FileMaker

• Validate/QA result files for accuracy in accordance with the facility contractual

rates

• Trend Audit files for best results

• Track recovery progress by monitoring weekly reports

• Follow-up with Payors on claim collections process

• Responsible for all collection communication

• Manage staff Goals and Objectives

HEALTHFIRST, New York, NY 2011-2012

Assistant Director, Claims

Reported to the Director of Claims, I was responsible for day-to-day functions in the Front End

Operations, Overpayment Recovery, Coordination of Benefits and Claims Long Term Care unit.

• Responsible for the oversight and timely handling of all claims function.

• Responsible for the oversight process and policy development, workflows, job-aids and controls

to ensure special contractual limitations are adhered to in regards to the audit process.

• Responsible for the oversight and timely handling of Underpayment/ Overpayment Recoveries

contributing to the overpayments and underpayments of claims. This includes trending and

analyzing system configurations contributing to Underpayments/Overpayments.

UNIVERSAL AMERICAN CORPORATION, CHCS, Pensacola, FL 2007 - 2010

Universal American Corporation is a specialty health and life insurance holding company offering a

comprehensive and affordable array of healthcare products, including a broad range of traditional health

insurance, Medicare managed care products, and Medicare prescription drug benefits coverage to

millions of Medicare beneficiaries.

Director, Claims Cost Containment and Recovery

Reported directly to Senior Vice President of Claims Operations; oversaw a global workforce with directly

supervision of 75 within Claims Recovery Team on and offshore. Claims recovery adjustments completed

for 2009 totaled 321,000, and collections processed for 2009 total $82,000,000.00.

• Requested by CAO to investigate and resolve an unidentified refund check

shortage issue: saved company more than $100k in less than one month through

analysis of backlogged refund checks and cleared up all outstanding items. Shifted

resources and created a now permanent 6-person team, and modified and created

policies related to batching systems procedures to avoid like future issues.

• Surpassed cost containment goal by $40M: Cost Containment unit was given an

annual goal to recover $5mil for 2009. Led team to actual recovery amount of

approximately $45M for 2009. This contributed to the creation of a formal recovery unit

with a staff of 25 employees, formal Policies and Procedures, and formal Auditing and

Training programs.

• Recognized by Senior Management for improving Cost Containment team’s TAT and

Accuracy for Payment Posting; reduced Administrative costs and reduced defects

through root cause analysis of the various overpayment reasons. Informed Sr.

Management of opportunities and improved the overall claims production performance.

JOSANNE BLACKWELL

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VISTA HEALTHPLAN, Sunrise, FL 1998 - 2007

Director, Claims Operations

Reported to the Senior Vice President of Operations, provided leadership for a multi-functional, high

production, service oriented staff of 50-100 associates.

• Oversaw the overall daily operational functions of the Claims Processing and Claims

Appeal units and ensured the regulatory and legal requirements for the claims and

appeals process were met.

• Reduced the overall appeals resolution time to 30 days, and implemented several

system enhancements to reduce the number of pending/denied claims.

• Increased service levels for the members and providers by conducting daily meetings

with Grievance and Appeals and Provider Relations Departments.

• Negotiated payments for services rendered by non-contracted providers, and reviewed

daily reports to meet the regulatory requirements for timeliness of claims payments.

Manager, Claims Quality Control, Cost Containment and Recovery and Provider Appeals

Reported to the Director of Claims and managed a staff of 20 associates in the oversight of all recovery

efforts, COB and TPL Cost Avoidance, Claims Adjustments, Macess and Electronic Claims Quality

Control and Provider Grievances.

• Improved total savings for organization by 250% in the first quarter 2000 compared to

1999.

• Implemented enhanced policy and procedures to expedite the recovery process.

• Restructured many workflows to improve efficiency and increase avoidance dollars.

• Implemented feedback process for Claims Department to reduce adjustments due to

examiner error.

Manager, Data Management

Reported to Director of Data Management and managed a staff of 10 Associates.

• Implemented standards for entry of configuration parameters to improve consistency

and overall performance of system.

• Facilitated bi-weekly meetings with the Claims Department to identify issues to increase

automation of the manual processes.

• Developed a Quality Control program for department to insure accuracy of configuration.

• Coordinated configuration audit that reduced overpayments by 15%.

• Established and implemented training sessions for Provider Relations to improve

contracting efforts.

• Reached and maintained a 5 day turnaround on all configuration requests.

OTHER EMPLOYMENT:

TENET NETWORK MANAGEMENT, Ft. Lauderdale, FL, Claims Manager-State of Florida, 1997-1998

PHYSICIAN CORPORATION OF AMERICA, Miami, FL, Claims Service Supervisor, 1994-1997

EDUCATION and TRAINING

Certificate, Situational Leadership, Fraud Waste & Abuse, Compliance, and Workplace Ethics

Nova University Current-Masters of Business Administration

Nova University-1998-2000 Bachelor of Science in Professional Management

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