Quality Improvement, Compliance, Audit, Managerial

Objective: To maintain a management position in a results-oriented

organization that seeks a career-conscious professional, where

acquired skills and education will be utilized toward continued

growth and advancement.

Experience: OptiCare Managed Vision, Rocky Mount, NC

2010 - Present

Manager, Quality Improvement

. Design and implement internal on-going and ad hoc

audits/reports to ensure quality/compliance standards are met

for all Medicaid, Medicare and Commercial products.

. Oversee outbound call center to ensure that HEDIS measures

are implemented and met.

. Manage operational policies and procedures for compliance

with state/federal laws and regulations and/or process

improvements/efficiencies as needed.

. Facilitate training programs with effective learning

strategies to strengthen departmental operations, to minimize

departmental performance gaps.

. Oversee quality improvement related activities/staff to

improve quality performance metrics and conduct risk

assessments to mitigate risks and effectively manages any

Corrective Action Plan (CAP) processes.

. Conduct external audits (includes travel) and facilitates

vendor management/oversight processes.

. Facilitate all client meetings and present quality

initiatives to executive management staff and clients to

ensure compliance/performance metrics are met.

. Develop quality and production standards for department

personnel using proven quantitative and qualitative methods

and oversee all internal/external audits and client requests.

. Conducts interviews and facilitates on-boarding processes for

all staff members.

Connectinc., Rocky Mount, NC

2009 - 2011

Career Counselor (Part-time)

. Provide services to NC unemployed adults in Dislocated Worker

program in the areas of reemployment, career building, job

retention, and asset accumulation.

. Provide clients with social support, counseling, information,

and community referrals.

. Educate clients of TAA, WIA, and TANF benefits including:

income support, job support and training allowances,

relocation assistance, tax credit for health insurance cost

(HCTC), and transportation subsidies.

Boice-Willis Clinic, Rocky Mount, NC

2008 - 2010

Insurance Specialist

. Responsible for the analysis of insurance payments to

determine if payments meet contractual terms.

. Analyze under payments or lack of payments such as

registration issues, denials, posting and coding errors.

. Reviews outstanding insurance accounts receivable to

determine if payments are in compliance with timing specified

in contracts.

. Aggressively pursue collection of high dollar patient account

balances.

Blue Cross Blue Shield of North Carolina, Durham, NC

2004 - 2008

Intake Specialist

. Processed admission notifications for medical necessity

review and Prior Plan Approval from providers and

policyholders in Utilization Management.

. Educated clients in areas of enrollment and self-management

health programs; provided direct support to case management

clinical staff.

Claims Specialist

. Processed and adjudicated medical claims in the Adjustment

and Refund Department for the NC State Health Plan, State

PPO, NC Health Choice and Commercial Government Operations.

. Analyzed insurance claims to determine extent of carrier's

liability.

Customer Service Specialist

. Handled inbound calls from subscribers and providers

regarding insurance coverage, benefits and claims.

Education: Mount Olive College, RTP, NC

B.S. in Business Administration - Health Care Management

August 2009

Additional Skills: Demonstrated proficiency with MS Word, MS Outlook,

MS PowerPoint, MS Access, MS Excel, Visio and Crystal Reports.

SQL experience and project management experience; currently

seeking Project Management Professional (PMP) certification.

Exhibits strong analytical, planning, problem-solving, oral,

written and presentation skills.

References available upon request

Contact this candidate