Customer Service Project

JOHN ROCHARD

**** ********* **.

Denver, CO ***05

Cell: 720-***-**** / Work: 720-***-****

EMPLOYMENT

Colorado Access ( 2008 -2010 )

. Claims / Appeals Manager

Kaiser Permanente (2007 - 2008)

. Project Coordinator

Colorado Access (2001 - 2007)

. Claims / Appeals Manager

. Claims / Appeals Supervisor

. Sr. Project Coordinator

. TPL Insurance Specialist

. Claims Trainer

McKesson / HBOC (1998 - 2001)

. UM Department Supervisor

Sloans Lake Managed Care (1996 - 1998)

. PPO Specialist

. Customer Service Representative

Advantage Clinical Lab (1994 - 1996)

. Customer Service Supervisor

SUMMARY OF QUALIFICATIONS

Over 14 years of Health Care Administration including: Medical Billing,

Collections, Accounts Receivable, Project Coordination, HEDIS Reporting.

16 years of Customer Service, Claims Training, Supervision, Medical

Terminology, ICD-9 and CPT-4 Medical Coding. Computer knowledge including:

Excel, Microsoft Word, Power Point, Access. Claims auditing, Appeal

knowledge, Coordination of Benefits. Ten-key by touch at 12,500. 50-60

WPM.

HIGHLIGHTS OF EXPERIENCE

Project Coordination:

. Managed the Colorado Access Coordination of Benefits (COB) project,

including the design, coordination, installation and implementation of

processes resulting in a $250,000 savings to the organization.

. Researched and completed projects initiated in the Claims, Provider

Network Service, Corporate Compliance, and Legal departments, ensuring

corporate compliance with applicable regulatory requirements, external

laws and accreditation standards.

. Researched potential cases of fraud and abuse.

. Tracked and trended claims processing errors, identified training issues,

and created new workflows to mitigate concerns.

. Tested products in the claims system for accuracy.

. Reviewed provider contracts and verified system specifications,

development, configuration to ensure correct contract administration.

. Produced system design documents, assisted with system testing, evaluated

system changes (including end-user needs and impacts) during all phases

of installation.

. Reviewed and presented information for HEDIS audits.

. Analyzed and resolved complex issues relating to manual and automated

claims processing, customer service, and financial processes.

. Liaison between outside vendors and Colorado Access

. Researched and documented current policies and procedures and recommended

changes to accommodate cross-functional efficiency.

. Initiated and conducted project meetings to maintain communications,

document project issues and progress, and secure decisions.

. Designed, prepared and maintained training and user reference manuals.

. Maintained a working knowledge of EDI daily functions including 834, 835,

837, 270, and 271 electronic transmissions.

Claims Processing / Appeals Supervision/ Management:

. Supervise the daily operations of the Claims department including:

service levels, employee performance, personnel issues, adhering to

departmental budget, and regulatory compliance requirements.

. Conduct regular all-staff meetings along with monthly one-on-one direct-

report meetings.

. Interview non-clinical candidates and hire staff as needed.

. Coordinate new-staff training and conduct regular coaching sessions.

. Write quarterly and annual evaluations for direct-reports.

. Manage claims inventory, monitor staff accuracy and production, identify

and trend system issues, and lead weekly meetings with other departments

to improve workflows.

. Monitor inbound calls to ensure customer service standards.

. Test system releases and update department Policies and Procedures.

. Coordinate Medicare APC pricing.

. Liaison between Reinsurance / Subrogation companies

. Contact person for appeals and claims issues with BHI

Staff Training:

. Developed and delivered insurance product training for PPO, HMO, POS and

indemnity products.

. Developed and delivered Coordination of Benefits training claims system

applications.

. Created and modified departmental workflows.

. Developed training database, facilitator guides, and job aides.

. Designed, documented and delivered Medicare specialist training program.

. Wrote Medicare claims-processing training materials and associated

compliance manuals for Colorado Access, McKesson / HBOC, and Sloans Lake

Claims departments.

. Designed and delivered customer service and claims processing cross-

training seminars to Customer Service Representatives.

Customer Service:

. Created responsive solutions to sensitive or complicated situations by

facilitating policy or procedural changes.

. Resolved and responded to customer inquiries relating to all major

aspects of corporate operations.

. Screened inquiries and collected information necessary to reply

appropriately to customer inquiries.

. Coordinated corrective actions of appropriate support personnel.

. Conducted all necessary follow-up activities.

Additional Areas of Expertise:

. Scheduling, Payroll, Auditing, Collections, ICD-9 and CPT Coding, and

Accounts Receivable.

REFERENCES AVAILABLE UPON REQUEST

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