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Management Medical

Location:
Little Falls, NJ
Salary:
65,000.00 - 70,000.00
Posted:
June 30, 2016

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Resume:

Jill Harland

Little Falls, NJ *****

973-***-****

acviq5@r.postjobfree.com

PROFILE:

I am currently handling all leave of absences for Robert Wood Johnson University Hospital, including all appeals and grievances with NJ State Disability.

My duties also include on boarding and group interviewing. Participation in New hires Orientation/fair.

Prior to this I was on the Pricewaterhouse Coopers & American Express teams at Xerox servicing employees throughout the country, which includes policies and payroll coding for short-term disability and FMLA, State FLA, Military, Workman’s Comp and Personal Leaves of absence.

I have also succeeded in member and Provider services, claims, training, quality, also Provider credentialing, contracts and fee schedules. I participated as a voting member on Aetna's Northern NJ grievance and appeal panel, with our Medical Directors, which heard second level appeals and denied services. Other projects I have managed include HIPPA and HEDIS. I have also prepared Prudential and Aetna's quality assurance for the successful accreditation for NCQA. I set up a successful monitoring center for a small home healthcare company, which included complete medical records access.

Demonstrated ability to handle high case volume and work under pressure.

**I earned my HRM certificate from Rutgers and seminars through NJIB.

EXPERIENCE:

August 2015 – May 2016 Human Resource/Leave of Absence Coordinator

Robert Wood Johnson University Hospital – New Brunswick, NJ

Coordinated, administered, communicated and recorded all Leave of Absence Policies and Disability applications in a timely manner while complying with all applicable laws for approximately 9,000 Employees.

Oversees the processing of all leaves of absence, ensuring employees and their department management

are notified in a timely manner on the status of the request.

Reviews and approves leave of absence claims based on eligibility for the Family and Medical Leave Act (FMLA).

While working with our PMA Group, I handled all Workers Compensation claims while registering them with NJ State Disability.

Provided guidance to all Directors regarding all the various Leave of Absence Policies/Disabilities/Return to Work processes.

Coordinated all supplemental pay with our payroll department.

Completed all Employee Appeal and Grievances with the NJ State Disability unit.

Maintained the following systems: Kronos, Lawson and Q-Cera.

March 07- August 2015 Human Resource Specialist

Affiliated Computer Services - Little Falls, NJ

> Outsourced Team Member working on Pricewaterhouse Coopers Personnel Human Resource needs of approximately 36,000 employees.

> Outsourced Team Member working on American Express Personnel Human Resource needs of approximately 31,000 employees.

> Worked primarily with company approved leaves of absence, including both short term and long term disability benefits.

> Explained policy and procedure to employee, management, time keepers and payroll.

> For eligible employees; worked directly with employee, management teams, payroll and external medical insurance companies to determine approval or denials of claims.

> On leave denials; contacts and discusses with employee and their management team why leave was denied. Offers alternative leave options.

> Maintains applicant PeopleSoft database and highly confidential employee records.

> Deals with insurance company on the number of claims entered each day and inputs each into PASS system. Claim types include FLMA, STD, and Return to Work confirmations.

> Provides exact payroll coding for all leaves.

April 2006 - January 2007 Long Term Disabilities Claim Manager

Prudential, Livingston, NJ

> Analyzed benefits for approval or deniability all claims for Disability Income, offset by state disability benefits.

> Effectively interacted with claimants, employers, physicians, attorneys and underwriters to gather information for claim.

> Matched the DX code with a duration code and set a time limit for the benefits.

> Evaluated claimant eligibility based on the employees years with the company and the percentage of LTD benefits chosen and paid through their salary.

> Determined payment period with follow-ups to monitor both payment accuracy and timeliness.

> All cases followed to closure of claim.

> Specifically chosen to manage complex disability cases such as AIDS, Renal and Kidney failure claims.

> Final resolution of claim could include specialty consulting resources such as individual telephone conferences with medical directors, company law teams and senior management for funds that would accommodate specific disabilities.

> Met weekly with management to discuss all findings and decisions.

> Provided technical direction to other claims personnel as needed.

June 2005 - March 2006 Monitoring Center Coordinator

Basic Home Infusion, Fairlawn, NJ

> Authored 22 new Policies and Procedures for company.

> Coordinated registered nurses, pharmaceuticals and patient alarm dates per individual Medtronic(r) infusion pump cycles for proper clinical visits

> Double checked for accuracy all telemetry read-outs, per patient/nurse visit.

> Updated 115 patient charts and spreadsheets.

> System; CPR and ACT

1999 - December 2003 File Manager, Contracts

Aetna US Healthcare, Fairfield NJ

> Assembled physician and other provider contracts and amendments with appropriate insurance and other pertinent credentials for execution.

> Reviewed all provider contracts for Health Insurance Portability and Accountability Act (HIPAA) compliant CPT codes.

> Sorted, tracked and reported provider results of each of the quality measures for Health Employer Data Information Set. (HEDIS)

> Reviewed current credentialing for approximately 10,000 provider/physician contracts for National Committee for Quality Assurance (NCQA) accreditation.

> Independently handled the verification of providers/physicians state licenses, CDS, DEA and malpractice insurance information for the NJ State Regulation Malpractice project of 2000, 2001 & 2002.

> Participated as a voting member on Aetna's Northern New Jersey grievance and appeal panel that heard second level member appeals of denied services.

> Trained new employees to facilitate high levels of productivity and efficiency

> Proficient in Aetna's internal strategic contract management system (SCM).

1991 - 1999 Provider Relations Representative

Prudential Insurance Company, Iselin, NJ

> Educated providers/physicians with respect to their contracts with Prudential..

> Prepared and provided current fee schedules for CPT codes requested.

> Scrutinized all provider applications for credentialing.

> Troubleshooter between New York, New Jersey and Pennsylvania offices for boarder overlap issues; including but not limited to provider/physicians with multiple state licenses.

> Implemented a provider service line.

> Reviewed and corrected provider rosters pertaining to capitation and claim issues.

> Tabulated and investigated all appeals and technical referrals for reporting to senior management and resolution.

> Followed up for pertinent information on all pending medical files for submission to the local market Medical Director.

> Serviced as liaison for medical consultants and appeals team members.

> Updated weekly reports from Prudential Membership Documentation System (PMDS) for quarterly review.

> Implemented and maintained a tracking and trending system of all incoming provider appeals.

> Facilitated the transition of contracts and files between multiple offices.

> Claim processing responsibilities included medical, dental, Coordination of Benefits, Medicare and other project work as assigned.

> Responsible for training and quality review of newly hired claim processors.

In house training: Quality of Care; Medicare/Medicaid; Coordination of Benefits; Case Management; ARGUS System Pharmaceutical; Billing and Eligibility.

Software knowledge: Microsoft Office, Windows, Excel, Word. Host system: PeopleSoft, PASS, CPR, ACT, SCM, PMDS. Lotus, Outlook, Kronos, Lawson, Q-Cera



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