Project Manager Customer Service
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Title:Technical Project Lead
abpy2f@r.postjobfree.com
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NAME: Maureen Reid
ADDRESS: **** ********** ***
CITY: Bradenton
STATE/PROVINCE: FL
ZIP/POSTAL CODE: 34202
COUNTRY: USA
EMAIL: abpy2f@r.postjobfree.com
PHONE: 941-***-****
CANDIDATE ID: 102800
CITIZENSHIP: US
Citizen
EDUCATION: High School
EXPERIENCE: 15
WILL RELOCATE: No
RELOCATION INFO:
JOB WANTED: Any
RATE NEEDED: 65,000 and up
HOMEPAGE:
COMMENTS:
HOTSKILLS: HIPAA Knowledge
ESUME
MAUREEN REID
6559 Meandering Way
Bradenton, FL 34202
abpy2f@r.postjobfree.com
PROFESSIONAL EXPERIENCE
HealthPlan Services
Tampa, Florida
HIPAA/EDI Coordinator
11/2000
Present
Actively attend workgroups and symposiums, participate in the Central Florida regional
HIPAA group, WEDI/SNIP business, translation, and testing workgroups, and am a voting
member with DISA X12N national standards setting organization.
Instrumental in recruiting, interviewing and retaining consulting firm to assist
organization with HIPAA compliance.
Co-leader with Project Manager all aspects of project from scope definitions and
feasibility/benefit analysis through implementation and evaluation of results.
Assess current EDI activities, applications, data entities, and practices to determine
level of HIPAA compliance.
Prepare work plans, status reports, conduct status briefings, and manage contact with
clients.
Identify and coordinate internal/external project team resources, recommend timeframes,
provide remediation assistance, and conduct process mapping and reengineering design
workshops.
Define and implement strategic electronic commerce solutions as needed.
Ensure project deliverables are accomplished on schedule and within budget while
minimizing operational/financial impact.
EDI Business Analyst
Lead cross functional and/or cross divisional work teams to identify and document
functional requirements, workflow, information sources, distribution paths, and system
specifications.
Primary liaison between IT development teams and business owners.
Meet with trading partners to promote the use of EDI for the exchange of business
information.
Analyze trading partner implementation guides in conjunction with company business
processes to develop mapping specifications that will improve operational efficiency in
the organization.
Create document abstracts/summaries of EDI and HIPAA documentation as required.
Train new and existing staff members in EDI/HIPAA activities, procedures, processes,
and responsibilities.
Ohio Health Group
Worthington, Ohio
Business Analyst
3/1999
-10/2000
Worked with customers to develop requirement specifications.
Recommended, coordinated, and facilitated business changes.
Studied existing information processing systems to evaluate effectiveness and develop
concepts for new systems.
Designed applications, built and executed test plans. Made recommendations to modify,
enhance process based on assessment.
Prepared technical reports, memoranda, and instructional manuals for systems, train and
support customers in production.
Lead project manager for Oracle7 to Oracle8 migration.
Developed and supported web based application for viewing provider panel.
Regional Provider Network Reimbursement Manager
Researched and implemented for assigned region recruitment activities to develop a
viable network.
Negotiated contract terms and conditions, including reimbursement for individual
practitioners, provider groups, hospitals, and PHOs.
Contributed to the overall effectiveness of the network by identifying provider issues;
researched and coordinated with other internal departments to recommend prompt and
accurate solutions.
Participated as part of a regional team in planning and carrying out overall company
business strategies and activities.
Analyzed present forms of reimbursement, compared to industry benchmarks then
determined standing relative to competitors.
Developed and maintained provider reimbursement strategies/methodology in risk
arrangements.
John Alden Life Insurance Company
Dublin, Ohio
Network Development Product Manager
8/1992
-1/1999
Instrumental in developing and maintaining contracts with Managed Care PPOs, HMOs, POS,
and Ancillary providers within a 40 county area of Ohio.
Interacted with marketing department to coordinate a strategic plan that encompassed
goals for contracting, increasing payer relations, interfacing with staff and increasing
potential marketing opportunities.
Resolved provider concerns and issues relating to the contract negotiated fee
schedules, claims repricing, and eligibility.
Coordinated Managed Care activities which included ensuring the completion of the
application process, introducing the contractual requirements, and initiating marketing
opportunities.
Contract development such as identifying agreement issues, negotiating non-standard
terms, revising and renegotiating as required.
Maintained proficiency in industry trends and made recommendations for new products.
Managed Care Network Specialist
Resolved operational and administrative issues associated with the maintenance of
existing Managed Care contracts.
Established and conducted audits to ensure compliance with contract terms. Provided
input for systems development.
Developed project plans and managed the implementation of new contracts and changes
resulting from renegotiating of existing contracts.
Handled initial review and evaluation of reimbursement methodology. Provided direction
and input for financial analysis to determine overall effectiveness of network.
Implemented guidelines for provider credentialing and created training manual to
standardized procedures.
Responsible for the collection and editing of provider information to produce provider
directories and welcome letters.
Claims Assistant Supervisor / Auditor Trainer
Handled 75+ customer calls weekly while maintaining 90% accuracy rating.
Created workflow guidelines, auditing procedures, and training manual. Provided
training and education as needed.
Performed supervisor functions when appropriate.
Customer Service Representative
Handled 100+ calls daily while maintaining company standards of 90% accuracy.
Responsible for regional accounts which included claims payments, adjustments, and
Insurance Compliance.
Addressed customer concerns and complaints.
CERTIFICATIONS AND EXPERIENCE
HIPAA Tactical Planning Workshop Certification, EC/EDI Coordinator Certification,
EC/EDI Implementation, Introduction To XML for Business Data, Introduction to Health Care
EDI Standards, PGP Security; Privacy Prescriptions for Healthcare.
Proficient with T.O.A.D. (Tool for Oracle Application Developers), Data Junction,
Visual Basic, Oracle/Microsoft SQL Server, Neon/Paperfree Winmap translator tool, EDI
(Electronic Data Interchange), XML, HTML, Visio, Windows NT, Windows 2000.
Extensive Knowledge of Word Perfect, Microsoft Office, Adobe Acrobat, Cactus, GMS,
Amisys, Claimfacts, CICS and CSC Claims Systems.
REFERENCES
Available upon request
Contact this candidate