Medical Management
Resume:
MARX CLARK, SR.
**** ********** *** ************, ** 46226
**********@*****.***
CAREER SUMMARY
A dedicated, results-driven, and innovative healthcare professional with 24 years of expertise in the area of federal and state Medicaid regulations and compliance. I am often viewed as the “go-to expert” in my understanding of these programs. This level of expertise has allowed me to conduct independent consultations with physicians on medical cases, Medicaid claims, benefits and processing for both the provider and client. I serve as a role model and leader for junior consultants, business analysts, and administrative staff, always employing sound business and professional judgment in these activities, often performing and assuming the role and responsibilities of the acting supervisor when needed, including reviewing critical case decisions and reporting for executive management through the MRT/ICES system. Identify gaps to ensure a win-win partnership is created while delivering sustainable client value.
CURRENT SKILLS
Client Relationship Management
Program Management
Determine Medical Eligibility
Healthcare Compliance and Risk
Strong quantitative skills and able to analyze and interpret Medical findings
Able to work effectively with all members of project teams
Able to work independently and consistently achieve excellent results
Strong oral and written communication skills, including presentation skills
Ability to research, analyze and interpret policy, legal briefs and regulations
Expertise in managing and presenting data in MS Word, and other software
Strong analytical and planning skills
Strong collaborative and team skills
Demonstrated ability to build effective partnerships and influence others who may have different perspectives
Knowledgeable of current trends in care management and industry standards related to care delivery to the Medicaid population
PROFESSIONAL EXPERIENCE
State of Indiana 1999 – Current
Family & Social Services Administration (FSSA)
Sr. Healthcare Consultant (Medicaid) – Extensive experience in the administration, management and compliance of Medicaid eligibility and appeals; review of medical reports and records along with recommendations and guidance from other physicians, medical professionals and subject matter experts (SME), regarding allowable benefits to both the client and the provider; proactively identifies issues through data/trend analysis, facilitates communication to stakeholders, prepare action plans to communicate relevant issues and coordinate/support implementation process; facilitate documentation and formalization of analytical review processes; manages the activities of personnel in the Medical Review and claims department; coordinates specialized clinical and financial reviews of complex cases; supports Medical Review management activities to include interviewing, employee selection, training, motivating, evaluating, counseling, disciplining and terminating in compliance with EEO/AA goals and personnel policies of the organization; adherers to federal and national HIPPA guidelines; knowledge of medical billing procedures and reimbursement policies (e.g. CPT, ICD-9); extensive working knowledge of various health insurance products such as PPO, HMO, POS, and Indemnity; participates and routinely assumes a leadership role within the organization; expert knowledge of Medicare/Medicaid payment rules and guidelines for both federal and state.
State of Indiana 1991 – 1999
Family & Social Services Administration (FSSA)
Disability Claims Adjudicator – Reviews initial claims and applications and determines what medical and/or vocational information is needed; requests additional information from applicant and reviews data to see if it fits within the scope of the disability program; analyzes data including diagnostic and assessment tests for program applicability; contacts doctors, psychologists, and other health care professionals to obtain information regarding claimants physical and mental condition; specifies and authorizes payment for medical examinations and tests that determine the existence and extent of applicants' physical or mental impairment; evaluates occupational information to assess claimants' work potential; explains program eligibility and interprets medical and vocational information for claimants, their legal representatives, Social Security Administration officials, and other interested parties; composes technical explanations of decisions and personalized notification of applicants of program eligibility; determines disability benefits and authorizes payment to medical facilities; keeps current on changes in federal rules and regulations, court decisions and economics affecting claimants potential in the job market; composes letters, questionnaires, and forms; refers applicants to other programs for medical and vocational services; learns to adjudicate complex and court related disability claims.
Excellent knowledge of the federal and state statutes, regulations, and policies of the Social Security Administration pertaining to disability adjudication; medical conditions and terminology common to disability adjudication. In addition to good experience and understanding to performing initial screening and adjudicating initial medical claims considering Disability Determinations policies and procedures and Social Security Administration regulations; collecting and analyzing medical data for disability claim determinations; interviewing claimants to elicit sensitive information; writing adjudication reports and case documentations.
State of Indiana 1987 - 1991
Indianapolis Public Schools
Deans’ Assistant - Monitored, and assisted with administrative duties of deans’ office, cafeteria and classrooms. Completed discipline reports. Contacted and set up conferences with parents. Assisted with administrative duties and scholarship programs. Substituted for absent teachers in classrooms. Monitored hallways and cafeterias. Assisted with extracurricular activities and performed related duties as required.
EDUCATION
M.A., Management and Leadership Organization, INDIANA WESLEYAN UNIVERSITY
B.S., Business Administration & Counseling Psychology, BALL STATE UNIVERSITY
TRAINING
2015 FDA Regulatory Compliance Training (HIPPA)
2015 Sexual Harassment Awareness and Compliance Training
2013 BTO Six Sigma Overview
2005 Rapid Improvement Facilitator
REFERENCES FURNISHED UPON REQUEST
Contact this candidate