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Medical Management

Location:
Charlotte, NC
Posted:
March 22, 2018

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Resume:

China Shaw

PROFESSIONAL PROFILE

Diversified experience in supervision, and comprehensive problem resolution abilities.

Clear, concise verbal and interpersonal communicator; interface well with multi-cultural staff.

Analytical, detail oriented, highly organized, and attentive to priorities and deadlines; work well under pressure.

Qualifications

Anthem Blue Cross, Wall Street NY

Risk Adjustment Coordinator Present

Outreach provider hospitals and other medical facilities to obtain records for coding.

Schedule on site chart reviews for coders.

Rename and assign files for the team and report to quality.

Perform multiple administrative functions for a team of 10 coordinators.

Upload all incoming mail and communication including invoices from third party vendors for accounting.

Arrange for payment for third party vendors.

Assist providers inquiries regarding coding with for Risk Management via arrangement with RN dept.

Generate all communication from corporate for quality review for coding purposes.

Assist with onboarding of all new coders.

Arrange updates for meetings regarding for entire North East division and Southern division of Anthem.

Manage all updates and report to quality and compliance

Manage multiple spreadsheets in Excel for coders.

Quality assure all coming files claims correspondence and update spreadsheets for department.

Order supplies for department.

Centers Plan for Healthy Living, Staten Island, NY 3/2016- Present

Lead Complex Care Coordinator / HEDIS Specialist

Provide clinical coordination of care under the supervision of Complex Care Nurse.

Conduct initial and ongoing assessments of high, low and moderate risks members via phone review.

Organize and conduct departmental meetings with coordinators for process improvement purposes.

Train and mentor new hires to ensure that all departmental standards are met.

Support the clinical team by performing all non clinical tasks including discharge summary request, adhoc complex care projects and help members initate the appeals and greivance process.

Document daily activities including calls, problems, interventions and outcomes.

Provide ongoing support for improving overall HEDIS and Star measure quality of care/service through the development, collection, monitoring, analysis, and management of Quality Improvement.

Follow-up with Physicians as indicated by HEDIS measure monitoring to obtain medical record information.

Anthem Blue Cross of NYC 7/2014-2/2016

Admin Provider Relations/ Marketing

Provided support for 12 team member Provider Relation Representatives staff.

Composed and prepare a high level of correspondence, presentations and spreadsheets.

Assembled all marketing materials for field team and marketing pf both departments.

Collected and maintained intake information from the field for management.

Helped to initiate the FIDA program launch program by collecting data and maintaining spreadsheets.

Scanned and maintained all departmental faxes, educational materials for on line provider portal.

Maintained CAQH information for provider relations and senior management.

Worked on various special projects and multiple departments.

Handled all calls to NYNM providers for issues and initiated all documentation for A&G.

Horizon Blue Cross and Blue Shield of New Jersey 6/2012 -4/2014

Medical Policy Specialist/Utilization Management

Reviewed all EOB and screen for medical eligibility and criteria for medical payment.

Reviewed all workers comp cases for review and analyzed and paid claims of high dollar amounts based on policy and needs.

Collected all information for Medical Director review regarding hospital billing.

Answered heavy outbound calls for HEDIS outreach of measures needed for annual measures.

Performed all data entry function of information updated by Provider Relations. & worked on various special projects for multiple departments.

Updated on a quarterly basis criteria for pre-ex management department review.

Trained new hires across 3 departments in HBCBS.

EDUCATION

Morgan State University, Baltimore, MD

Associates of Business Administration – Business Management - 1984



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