Customer Service Quality Assurance
Resume:
Madeline Goldberg
Bellflower, California 90706
*******@**.**.***
Objective:
To obtain employment in Operations/Compliance/Claims/Provider
Service/Customer Service, where my expertise will assist in achieving
corporate goals.
Employment History :
Sr. Director Claims/Compliance/Appeals/Audit/Customer Service
Regal Medical Group, Inc. Northridge, California/Arcadian Management
Services, San Dimas, California
3/2008 - 6/2009
Supervised 30 employees
Performed Analysis and Developed Process Improvement Plan
Developed interdepartmental workflows: Eligibility/UM/Contracting
Developed Customer Service Tracking Tool and Global viewing of claims and
authorizations across 16 databases
Created consistent criteria and efficiencies in the Audit process
Increased auto adjudication
Developed process for scanning to reduce paper claims
Improved relationships with contracted Facilities
2007 - 2009
Consulting while seeking full time employment
Energy Enterprises
Call center training
Provider Reimbursement contract analysis
AVP Operations
Director Provider Services
4/2002 - 9/2007 Universal Care, Signal Hill, California
Supervision of 20 employees
Managed Claims/Appeals/Compliance
Implementation of system upgrades and maintenance
Key member of Transition team between Universal Care and Health Net
Responsible for all Customer Service (Members/Providers/Vendors)
Quality Improvement Team member
Director, Corporate Compliance Auditing/Special Projects/Provider Services
Universal Care, Signal hill, California
Supervised 6 employees
Managed claims and finance issues for Contracted Medical Groups -
Coordinated JOM's
Developed working relationships with IPA's and CMG's
Created Corporate Compliance Auditing Department
Developed and Implemented an online automated tool, tracking and reporting
methodology to insure corporate compliance
Director, Claims
3/1998 -8/2001
Molina Healthcare, Long beach, California
Supervised 25 employees
Managed budget of $1,500,000 yearly
Responsible for the oversight of the Claims Department including
Production/Quality /Appeal standards
Created training programs
Developed and implemented new processes for the Department eradicating a
25,000 plus backlog of claims
Migrated the Commercial product in-house saving Molina Healthcare $100,000
in a three month timeframe
Assisted in the transition of Molina Healthcare's newly acquired Health
Plans to Molina Healthcare's systems
Interfaced with all internal departments/sub-contactors/vendors
Member various committees including but not limited to: Quality Assurance,
Medical Review, Transition and Compliance
Interfaced wit DHS/HCFA/DOC regulators on all compliance issues
Manager, Claims
1995 - 1998
FHP Inc/Pacificare, Cypress, California
Supervised 75 employees
Responsible for production
Oversight of budget
Assisted with system migration and acquisition transition
Implemented HFCA/DOC regulatory compliance
Worked with Medical review and Case management to negotiate discounted
rates
Interfaced with Members, Providers and all internal departments to review
and resolve issues
Education
California State University, Haywood, California
1972-1973 California State University, Northridge, California
1970-1972 San Jose State University, San Jose, California
B.S. Speech Pathology and Audiology
Memberships
Western Claims Conference
Orange County Life and Health Claims Association
Los Angeles Claims Association
References are available on request.
Previous employment has included self funded groups, IPA's and MSO's.
Contact this candidate