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Customer Service Project Manager

Miami, Florida, 33137, United States
March 28, 2011

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*** ** ** ******, #*** * Miami, FL 33137-3911____ * Mobile: (917) 570-4324__* E-mail:


Highly accomplished and results driven management executive with more than 24 years of experience managing

operations, claims administrations, billing & collections, provider services, quality control, and call center

environments. A proven record of accomplishment in building, leading and managing teams, overseeing budgets,

operational issues while maximizing opportunities to improve top and bottom line results. Knowledgeable in all

aspects of insurance industry practices, federal/state and HIPAA compliance legislation, NCQA,

hospital/physician billing reimbursement principles, durable medical equipment, and product lines of business

including Commercial, HMO, POS, PPO, Medicare, Medicaid, COBRA, Pharmacy, Dental, and Vision.

Professional strengths include:

Operations Management Governmental & Regulatory Compliance

Policy & Procedure Development Team Building & Performance Improvement

Revenue Cycle Management Re-engineering Operations & Process Improvement

Customer Service, Satisfaction & Retention CPT/ICD-10, HCPCS, DRG Coding & Guidelines

Billing, Collections & Cash Management Inventory & Quality Control


Home Advertising Network, Inc., New York, NY… 2003 - 2009


Lead the strategic planning process, initiated growth strategies, operations structure, billing systems, approved all

major financial management, new product development initiatives, contract management, and revenue cycle

processes. Built a dynamic management team of 4 direct/24+ indirect FTEs, recruiting a diverse cross-section of

outstanding industry experience within marketing, member services, IT, finance, billing & collections, and

accounts receivables. The company website attracted nearly 1 million members, and more than 2 million views

monthly. Founded, grew and sold the company for $3.8 million in 2009.

Center Care Health Plan, New York, NY… 1999 - 2003

Director, Claims Administration

Accountable for the overall strategic direction of a large Medicaid Managed Care claims department (65 FTEs / 4

managers) processing in excess of 58,000 claims, 14,600 calls, 650+ appeals per-month. Directed functions

involving mailroom, EDI/imaging, claims processing, call center, provider/member correspondence and enquiries,

collections, budgeting, COB, quality control, and training. Prepared weekly, monthly, and quarterly reporting to

assess departmental performance indicators, claim cycle time, IBNR, processing accuracy, call abandonment rate,

and productivity achievements towards stated goals and objectives. M aintained average claims turnaround time

within 6-8 days, and accuracy rates (>99.5%). Setup fee tables, special provider rate schedules, and pre-audited

check run report.

Significant Contributions:

Carried the company through 4 consecutive years of zero deficiency during Article 44 and IPRO state


Reduced provider reimbursement complaints by 45% by establishing a policy that would replace an out

dated fee schedule with current year outpatient rates by facility.

Established performance standards in both claims production and customer service best suited to meet the

strategic and operational goals of the claims department.

Developed and implemented the company’s first policy & procedure manual for handling Medicaid, CHP,

Fee-for-Service, Encounter Data, COB, DME, and Collections via CSC. This improved claim analysts’

effectiveness & efficiency, reduced claim decision cycle times and thereby improved customer service.

Identified and implemented new business systems that generated $500,000 plus in savings yearly.

Initiated numerous quality and process improvements through proactive management that addressed claim

issues with key providers, hospitals and medical groups.

Wrote job descriptions, established pay grades and pay ranges on all exempt and non-exempt employees for

the entire claims operation.

Comprehensive Medical Management, Inc., New York, NY… 1997 - 1999

Director, Claims Operations

Directly responsible for managing the day-to-day operations of the claims department (33+ FTEs / 2 managers),

including the development of claims processes, structure, workforce management, claims coding systems, call

center, quality assurance, collections, enrollment, provider services, reconciliations, education, and contract

negotiations. Achieved all administrative cost targets including COB/TPL and finished each year at budget or

below targeted budget. Maintained claim turn-around within 5-6 days, pended claims under 20 days, and

improved provider inquiry calls by decreasing abandoned rates from 22% to less than 5%, reducing wait times and

improving service to providers.

Significant Contributions:

Participated in the design, development, testing, and implementation of a state-of-the-art claim adjudication

system that dramatically improved efficiency, and decreased overhead.

Increased claims payment turnaround times that resulted in provider satisfaction and reduction in claims

payment interest.

Appointed by CEO to rewrite the company’s HR Manual, including revising outdated policies to ensure

compliance, and adding new policies to improve moral.

HIP Health Plan of Florida, Hollywood, FL… 1996 - 1997

Manager, Claims & Customer Service

Managed the day-to-day functions of 54 union-employees in both the claims department and call center, ensuring

timely, accurate processing of claims in accordance to provider contracts, provider & member enquiries,

adjustments, pended/suspended claims, and department of insurance complaints are effectively and efficiently

managed. Maximized staff performance and training needs through performance management and performance

review processes. Developed, executed, and maintained the claims department policy & procedures and

processing standards for both Commercial and Medicare lines of business via the QCARE claims system.

Significant Contributions:

Re-engineered claims department workflow processes to eliminate 8-month backlog within 3-months and

maintained an on-going claims turnaround of 5-7 days.

Identified and made recommendation for process improvements in customer service that successfully

reduced abandonment rate from over 38% to a sustainable lever under 13%.

Developed and implemented productivity standards for claims service that significantly reduced telephone

calls, correspondence and department of insurance complaints.

Designs by Rodney, Inc., Miami Beach, FL…1994 - 1996


Owned and managed a retail store located in South Beach, Florida. Recruited, trained, and managed sales, store

employees, invoicing/billing, customer credits & collections, payroll, and on-line activities at Developed and managed end-to-end marketing programs including print, direct mail, e-

mail, and consumer catalogs. In January 1996, I sold the company.

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John Alden Life Insurance Company, Miami, FL…1990 – 1994

Senior Supervisor, Claims

Supervised a staff of 28 claims examiners performing eligibility, claims processing, collections, COB, hospital

audits, dental, and appeals. Personally set up and investigated medical billing for potential fraudulent claims.

Reviewed claims entered for over/underpayments to providers based on contractual rates. Worked collaboratively

with Provider Relations, Member Services, Legal, IT, and UM, improving and streamlining operational issues and

turnaround time.

Significant Contributions:

Assembled and managed a temporary claims unit in Minneapolis, MN following Hurricane Andrew in

1992. The office went from conception to fully functional in 2-months, capable of handling 18k claims per


Overhauled a department with a 6-month backlog within 8-weeks, and maintained an on-going claims

turnaround of 3-4 days.

Early Career – Blue Cross & Blue Shield of Florida

Launched career during and after college into roles as project manager to claims supervisor for Blue Cross & Blue

Shield of Florida where I gained valuable experience managing Medicare Part A, B & DME claims.


Jacksonville University * BBA - Bachelor of Business Administration * 1984-1988


BNA - Health Care Compliance Library Member 1988 - Present

The Executive Report on Managed Care Member 2004 - Present

Global Insurance Network Member 2009 - Present


Medical Terminology Certified in CPT/ICD-10, HCPCS Coding & Guidelines

Group Life & Health Insurance DRG Coding & Reimbursement Methodologies

Medical & Drug Reimbursement Knowledge of Governmental & Compliance Requirements

COB - Coordination of Benefits Human Resources Management


Microsoft Excel Lotus 1-2-3 PowerPoint Word Perfect

Microsoft Works Microsoft Access Photoshop Publisher Outlook & Outlook Express

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