Quality Assurance Customer Service

LYNN K. THAYER

*** ******* ****** ***** * Delaware, OH 43015

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

(home) 740-***-****

(cell) 614-***-****

A highly accomplished health plan executive with experience in management,

business development and implementation, technical development, project

management and claims administration. A results oriented leader with

success in team development, strategic thinking, and problem solving.

Known for a strong work ethic and commitment to the achievement of

organizational goals. Excellent technical and customer service skills with

a focus of quality and professionalism.

Qualifications

* New Business Development * Managed Care Plan Operations

* Project Management

* Technical Design and Support * Operations Management

* Mentoring

* Claims Administration * Physician/Hospital Contracting

* Staff Development

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PROFESSIONAL EXPERIENCE

Harrington Health- Westerville, OH 08/2008-present

Business Manager, BPO/Operations

. Effectively manage projects to ensure agreed upon scope, budget and

timelines are met

. Manage departmental staffing budget

. Manage daily operations to ensure agreed upon scope of work is delivered

while staying within budget

. Perform root cause analysis related to system driven processes

. Develop policy and procedures to support production and test environments

. Assist BPO clients in determining business requirements and scope of work

. Develop QA and auditing program to ensure accurate system configuration

and contract analysis

. Participate in quality assurance reviews

. Monitor client specific SLA commitments and other financial/operational

metrics

. Support design of new business

. Work cooperatively with client executives on items such as delivery

solutions and future design needs

Centene Corporation dba Buckeye Community Health Plan- Columbus, OH

12/2003-08/2008

Director, Claims Management Services

. Key role in operational start-up and implementation of new Medicaid HMO

. Assist with software upgrades, testing, and conversions

. Provide operational oversight for multiple departments

. Perform root cause analysis related to system driven processes

. Responsible for execution of work to ensure service level standards are

met

. Monitor State regulatory standards to ensure company compliance for

member and provider call centers

. Interpret physician and hospital contract language to support accurate

and timely claims reimbursement

. Assist in design and functionality of claims payment processing system

. Manage Health Plan based liability related to claims projects

. Apply knowledge of all types of claims processing and billing

requirements including CPT, HCPC, RCC, and ICD-9 coding

. Assist in development of marketing initiatives to support regional growth

and development

. Work cooperatively with provider/hospital executives to ensure

operational efficiency

Family Health Plan/Antares Management Service- Toledo, OH

1/2002-12/2003

Director of Operations

. Provide operational oversight for multiple departments

. Assist in RFP and company audit processes

. Manage software upgrades, testing, and conversions

. Coordinate operational structure and processes within multiple

departments

. Improved claims administration through system configuration and

application of state and federal billing guidelines

. Enhanced electronic and on-line claims system to meet state and federal

regulations and encounter data requirements

. Design and maintain software core-subsystem configuration to support

business and reporting requirements across multiple departments

. Develop benefit designs to meet needs of employer groups

. Interpret physician and hospital contract language to support accurate

and timely claims reimbursement

. Developed procedures for quality assurance and auditing programs

Medical College of Ohio-Toledo, OH 06/2001-1/2002

Contract Analyst

Coordinate, maintain, and negotiate third party payor contracts

. Analyze contract performance

. Coordinate contract renewals

. Negotiate single case agreements

. Work collaboratively with other departments on reimbursement and billing

issues

Burns Consulting Associates-Maumee, OH 08/2000-05/2001

Analyst

. Develop and analyze employer RFP requests

. Review hospital admission data for quality analysis

. Train Third Party Administrators on repricing procedures

. Aid in development of fee schedules

Paramount Health Care-Maumee, OH 10/1991-08/2000

Claims/Benefit Administration Team Leader

. Supervise and train a large staff with multiple job levels and

responsibilities

. Design and maintain claims processing software to support claims

processing and corporate financial reporting

. Design and maintain Amisys core-subsystem configuration to support

business and reporting requirements across multiple departments for

commercial, Medicare, and Medicaid lines of business

. Assisted in Plan reviews by HCFA/ODJFS

. Manage Amisys software upgrades, testing, and conversions

. Develop benefit designs to meet needs of employer groups

. Interpret physician and hospital contract language to support accurate

claims reimbursement

. Knowledge of all types of claims processing and billing requirements

including CPT, HCPC, RCC, and ICD-9 coding

. Develop action plans for physician offices and hospitals to increase

quality of claim submissions

. Collect and analyze claims encounter data for regulatory agencies,

employer groups, physician offices, and hospitals

Blue Cross Blue Shield-Toledo, OH 1990-1991

Provider Registration

. Maintain provider databases for TBS and TOPPS claims adjudication

systems.

. Assisted with system conversion from TBS to TOPPS

. Implemented training for new recruits

Professional Activities

. Attend ODJFS committee and regulatory hearings

. Attend and actively participate in the AMISYS Users Group Conference

. Participate on multiple AMISYS subcommittees

. Attend annual AMISYS Client Conference

Education

. Bowling Green State University 08/1981-01/1983

. AMISYS Benefit, Pricing and Provider Subsystem Certifications

. Continuing Education Classes

-Management Techniques

-Workplace/Employee Development

-Managing Conflict

-Project Management

Professional Skills

. Microsoft Office ? Impromptu ?

Business Objects

. Monarch ? Amisys /Claimfacts ?

Analytical Skills

. Excellent oral, written and organizational skills

Contact this candidate