Health Care Expert

ALICIA NELSON-JONES

*** ******** ****** . ********, ** 11203 • 917-***-**** • www.linkedin.com/in/alicianelsonjones • ******.***********@*****.***

HEALTHCARE EXECUTIVE

Reporting • Policies • Auditing • Customer Satisfaction

Performance driven healthcare executive with many years of experience working in health insurance for both hospitals and managed care environments with over five years dedicated to compliance. Proven analytical and communication skills. Possess a high level of ethics and integrity with the ability to resolve issues and achieve results. Demonstrated ability to work in a fast paced environment, motivate others, effectively delegate tasks, develop and lead teams and set goals. Excel in handling confidential matters and investigations professionally. Collaborate well with all levels of staff to accomplish desired regulatory goals as contractually required by Medicare, Medicaid, MAPD, MLTC and FIDA Plans. Demonstrated expertise in:

Regulatory Affairs and Compliance

Process Improvement

Investigations and Audits

Leadership and Team Building

Policy Development

Complaint, Grievances and Appeals

Training

Risk Assessment and Corrective Action Plans

HIPAA

Regulatory Reporting

PROFESSIONAL EXPERIENCE

Elderplan, Brooklyn, NY 2012 – 2016

One of the fastest growing managed care organizations in New York City serving over 320,000 members.

Director, Appeals and Grievances

Reported directly to the AVP of Medical Affairs. Implemented new workflows to eliminate duplicative procedures. Participated in interdepartmental committee meetings. Hired, developed and managed fourteen (14) employees. Reviewed and analyzed data related to appeals and grievances and the effect on member and provider satisfaction. Implemented Corrective Action Plans. Conducted internal departmental audits to identify areas of risk. Developed all Appeals and Grievances policies and procedures. Participated on the Star Champion committee as one of the champions responsible for maximizing the Plan's stars.

Tracked and trended to identify issues received regarding complaints, grievances and appeals to find root cause

Chaired the Appeals and Grievances committee which reported up to the QIC committee and Upper Management

Handled sensitive, confidential complaints

Provided vendor oversight for PBM, Transportation, dental and eye glass vendors

Oversaw and prepared regulatory reports and data validation for Medicare and FIDA

Create and conduct training concerning all Medicare Managed Care Manual changes that affect the department

Health Plus, PHSP, Inc, Brooklyn, NY 2008 – 2012

One of the fastest growing managed care organizations in New York City serving over 320,000 members.

Associate Director, Regulatory Affairs/Compliance (2008 – 2012)

Reported directly to the Vice President. Oversaw planning and preparations for regulatory CMS, State and City and audits. Coordinated compliance activities including the establishment, implementation and adherence to policies created to ensure the Plan met regulatory and contractual agreements to prevent illegal, unethical or improper conduct. Acted as Plan’s primary liaison with the oversight regulatory agencies on regulatory initiatives and developments. Built amicable relationships internally and externally. Served as a resource to Plan staff regarding regulatory requirements. Received HPMS memos and CMS guidelines, assisted impacted areas in implementing. Directed and managed six employees. Created and edit policies and procedures.

Identified potential areas of compliance vulnerability and risk and reported to Senior Leadership

Investigated member, provider and employee complaints and bring resolution to issues

Conducted monitoring activities for Operational areas

Implemented corrective action plans for resolution of problematic issues/complaints

Prepared regulatory reports for Medicare and Medicare

Created and conducted training concerning laws and regulations that affects operations

MetroPlus Health Plan, New York, NY 2007 – 2008

The #1 rated Medicaid Managed Care Health Plan in NYC for the last five out of six years.

Manager, Regulatory Affairs

Reported to the Associate Executive Director. Acted as the day to day liaison between Plan and regulatory agencies. Prepared plans of correction and ensured implementation in accordance with oversight agency. Reviewed Plan documents, policies and procedures for compliance with regulations and program contracts. Worked on Medicare implementation team. Prepared plan for Article 44 survey.

Implemented changes for new government requirements to contracts

Developed policies and procedures

Kept senior managers informed of regulatory requirements and changes

Submitted and obtained approval for marketing materials, handbooks and other plan documents as required

Actively participated in Compliance committee meetings

Memorial Sloan-Kettering Cancer Center, New York, NY 2005 – 2007

One of the world’s premier cancer centers, committed to exceptional patient care, research and educational programs.

Physician Billing Department Group Leader

Reported to the Supervisor. Supervised forty (40) Call Center Account Specialists. Handled escalated telephone inquiries with appropriate resolution. Prepared balance bills to patients.

Reviewed work files, developed action plans to meet departmental goals and submitted to upper Management

Adjusted patients' bills

Prepared and submitted monthly reports

HIP Health Plan of New York, New York, NY 2003 – 2005

Presently known as Emblem Healthcare. One of New York’s largest health insurance plans providing over 3.4 million people with affordable quality health coverage.

Grievance and Appeal Staff Coordinator

Reported to the Associate Director. Investigated, reviewed and responded to members’ complaints, grievances and appeals for Medicaid and Medicare lines of business in a timely and satisfactory manner. Mentored eight (8) employees, including performance reviews, counseling and creating action plans to meet goals.

Prepared and submitted cases to the Maximus for resolution

Interacted with governmental entities such as New York State Department of Health, New York State Attorney General’s Office, Centers for Medicare and Medicaid Services (CMS), New York State Department of Insurance and elected governmental officials

St. Vincent’s Hospital and Medical Center, New York, NY 2002 - 2003

Was a 758-bed tertiary care Catholic teaching hospital that placed an emphasis on patient-focused healthcare with

a special mission to provide care for the poor and disenfranchised.

Care Manager

Reported to the Director. Supervised four (4) staff members at offsite office. Monitored services provided to ensure compliance with hospital’s contractual agreement.

Screened insurance benefits, oriented patients on coverage and produced reports on usage of visits and payments received

Communicated and interacted with patients, families, social workers, case managers and physicians in coordinating treatment, discharge and other related services

Obtained prior authorization for inpatient stays

Empire BlueCross BlueShield, New York, NY 1996 – 2001

One of the largest health insurers in the United States, offering a variety of managed care plans and insurance.

Customer Service Representative

Responsible for handling 100+ calls from members and providers addressing health benefit and claim questions. Reviewed and responded to complaints from member within regulated timeframes.

Provided excellent customer service to Commercial, Medicare and Medigap members

Trained new employees on departmental workflow

Adjudicated claims

EDUCATION

Long Island University, Brooklyn, New York

Masters of Arts, Public Administration

Bachelor of Arts, Political Science

ASSOCIATIONS

Health Care Compliance Association (HCCA), Member

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