Manager Health

Alexika L Tucker 562-***-****

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

San Pedro, CA 90731

Professional Objective: Obtain a position that enables me to utilize my educational and clinical skills, preferably in

a direct outcome-based program that engenders healthy living and enhances the quality of life for individuals.

HIGHLIGHTS: SKILLS AND ABILITIES

• Excellent analytical skills, problem solving ability and strong critical thinking skills

• Skilled in design, implementation, data collection, analysis and presentation of results

• Experienced and proficient as a supervisor and staff trainer

• Exceptional oral, written and interpersonal skills

• Extensive knowledge of the healthcare industry including; claims adjudication, provider dispute resolution, CPT,

ICD-9 and HCPC coding, procedures and guidelines

• Strong working knowledge of MMC Chapter 2, PCUG and PDBM

• Experienced in planning, leading and facilitating teams to a common vision and developing strategies and plans to

accomplish objective

PROFESSIONAL EXPERIENCE

11/2010 – 02/2011: MOLINA HEALTHCARE, Long Beach, CA

Manager, Medicare Membership Accounting

Managed and provided direct oversight of the Membership Accounting Team. Assisted in the development of internal

desktop processes, policies and procedures and SOPs. Maintained appropriate departmental reporting statistics and

quality improvement practices.

• Managed direct reporting staff consisting of 10 full-time and 8 temporary employees

• Developed project plans which identified key issues, approaches, performance metrics and required

resources to ensure timely deliverables and successful completion of projects

• Oversight of Integrigard submissions, TRR processing, claims resolution processes and Acumen reporting

• Promoted and developed communication between lines of business and technical staff

• Provided substantive data on financial reconciliation and performance metrics as input into daily

dashboard reports

• Facilitated the preparation and analysis of monthly enrollment/disenrollment reports by state/health plan

• Facilitated revision of Membership Accounting Dept. P&Ps specifically; LIS/BAE, 4Rx, E&D Letter

Generation, Enrollment Intake and Validation Process and Transmission of Enrollments to CMS and

Enrollment Mechanisms

• Responsible for daily/weekly/monthly production reports

• Provided subject matter expertise in membership reconciliation and enrollment issues

• Completed yearly performance evaluations and goal projections utilizing Scorecards for direct reporting

staff

• Contributed to BRD in regards to reconfiguration of QNXT database requirements to support MARx

redesign

• Facilitated the documentation/reporting of substantive data required for internal CMS regulatory audit

09/2010 – 11/2010: UNITED HEALTH GROUP, Cypress, CA

Senior Physician Advocate/Provider Dispute Resolution, Los Angeles County

Senior point of contact for submission/resolution of Provider disputes. Responsible for developing and fostering

relationships with key providers to enhance UHG’s presence within the provider community.

• Managed, developed and maintained positive business relationships with new/existing providers to secure

strong partnerships and maintain revenue of products and services within assigned geographic territory

• Composed correspondence in accordance with regulatory requirements to reflect accurate claim disputes

in a clear, concise and grammatically correct format

• Monitored contract renewal dates and executed programs designed to retain existing provider network

accounts

• Coordinated workflow between departments and interfaced with internal and external resources

• Prepared narratives, graphs and flowcharts to be utilized for departmental presentations

• Designed and implemented programs to build and nurture positive relationships between the health plan

and key providers including physicians, hospitals and ancillary service providers

• Responsible for assuring the achievement and maintenance of departmental key performance indicators as

well as federal and state specific requirement/regulations

• Conducted new provider education including robust training programs such as quarterly webinars,

telephonic and in-service seminars

01/2008 – 09/2009: UNITED HEALTH GROUP OVATIONS, Cypress, CA

Provider/Member Relations Advocate/Claims Resolution

Served as a provider/member relations advocate to resolve complex claims issues and ensure provider/member

retention. Facilitated provider education in regards to claims dispute and billing and authorization procedures.

• Worked as critical integration point between providers and all functional areas until issues were

successfully resolved

• Created and maintained relationships across the organization to leverage support for MAPD

products including regulatory, benefit administration, claims and utilization management

• Tracked, maintained and documented product for benefit related issues and decisions, identifying

risks and escalating as appropriate

• Handled complex claims, adjudication, reconsideration and enrollment/disenrollment issues

• Acted as information resource for staff members and served as subject matter expert to call center

• Facilitated pilot project to track/trend misrouted calls resulting in decrease of 80% volume within

2 months of start-up

• Contributed to the achievement of department unit productivity and quality goals

• Provided detailed reports to upper management in regards to provider/member needs, perception

and improvement opportunities

01/2007 – 05/2007: WINDSTONE BEHAVIORAL HEALTH, Costa Mesa, CA

Supervisor/Project Director, Behavioral Health Wellness Pilot Program

Supervised and provided direct oversight of behavioral health wellness program consisting of 10 licensed clinicians

and 15 full-time employees

• Responsible for creating and implementing departmental staffing module

• Compiled data for monthly behavioral risk adjustment initiative reports

• Created P&P manual and operational/programmatic metrics report

• Formalized organizational charts

• Implemented and maintained effective employee personnel and progress report system

• Facilitated staff meetings and in-service seminars to ensure regulatory compliance

• Responsible for recruitment and training of clinical and support staff

• Formalized documentation for internal CMS regulatory audit

• Proactively identified process improvement opportunities and project initiatives that enhanced

organizational effectiveness

• Demonstrated and promoted teamwork to ensure member continuity of care and maintain positive

work environment

05/2003 – 01/2007: PACIFICARE/UNITED BEHAVIORAL HEALTH, Van Nuys, CA

Member/Provider Relations Advocate/Western Region Claims Specialist

Highly visible position responsible for Member/Provider dispute resolution and coordination of comprehensive and

culturally sensitive therapeutic behavioral health services for Orange County Medicaid members

• Worked directly with Orange County Mental Health Department and other agencies to provide

appropriate referrals and coordinate care

• Developed and maintained positive working relationships with participating physicians groups

(PPGs) and mental health facilities by conducting periodic on-site visits, communicating administrative

policies and procedures, regulatory requirements and facilitating the resolution of provider issues

• Conducted pertinent research to evaluate, respond and reconcile incoming provider disputes

accurately, timely and in accordance with established regulatory guidelines inclusive of appropriate

review of claims and prior claims payment history

• Conducted provider education including the customization/development of information reference

materials specific to assigned PPGs/mental health facilities to continuously improve knowledge and

effectiveness of the provider network

• Actively participated in internal meetings to implement necessary operational changes

• Contributed to company-wide claims improvement work group responsible for identifying and

streamlining claims workaround policies to increase efficiency and accuracy

06/1996 – 05/2003: LOS ALAMITOS UNIFIED SCHOOL DISTRICT, Los Alamitos, CA

Discrete Trial Training Program Facilitator

Responsible for developing, coordinating and implementing the District’s Autism program and related services in

classroom setting for developmentally disabled children ages 3-8 years

• Responsible for organizing and facilitating individual and group lesson planning

• Program data collection and analysis

• Individualized student progress assessment and program modification

• Intensive behavior modification and one-on-one Discrete Trial Training Therapy

• Utilization of various communication system and evidence based service training/research

programs i.e. PECS, ASL and TEACCH

• Community Based Instruction (CBI)

• Individualized staff training and progress assessment

06/1996 – 05/2003: GREATER ANAHEIM SELPA, Anaheim, CA

In-home Autism program facilitator

02/1992 – 04/1994: INNOVATIVE DIALYSIS, Long Beach, CA

Junior Accounts Manager

Accounts supervision of dialysis management company (20 centers nationwide)

• Accounts payable/receivable

• Payroll processing

• Assisted with facility contracting

• Assisted with Pharmacy Benefit Management (PBM)

• Account spreadsheet management

• Claims research and adjudication

• Month-end reconciliation reporting

• Annual fiscal reporting

11/1989 – 01/1992: LOS ANGELES COUNTY MUSEUM OF ART, Los Angeles, CA

Membership Accounting Representative and Art Rental Gallery apprentice

1989 – Present: Classical Piano Instructor

Self Employed

EDUCATION

Psychology-National University Costa Mesa, CA

TECHNICAL

Microsoft Office Suite: Word, Outlook, Access Excel, Power Point

QNXT, CRM, COSMOS, NICE, RIMS, UNET, FACETS, GPS, ORS, NDB, FRM, O/C Medi-Cal IRIS

Typing (80 wpm)

COMPANY SPONSORED TRAINING:

Building Physician Relationships, Whitewater Group, Chicago, IL 09/2010

Advanced Microsoft Office, Element K, Long Beach, CA 11/2010

Effective Management, Conflict Resolution, Long Beach, CA 01/2011

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