Manager Management

Shane J. Jones

**** ****** ****** ***** *** Jersey 07083

908-***-**** ************@*****.***

Management Professional

A Recognized Expert in Healthcare Operations, Experienced in All Aspects of Management

Comprehensive background in management of healthcare operations including claims management, benefits and recovery of overpayment across large prestigious organizations. Successfully led a Team to recover over $12 Million in claim overpayments. Strong expertise in promotion of internal policies and procedures, management of vendor sourcing and relations. Consistently rated as a top performer, recognized as a strong leader and reliable team player. Established good working relationships and collaborative arrangements with community groups and corporate organizations to help achieve the goals of the organization.

CORE COMPETENCIES

Healthcare Management Claims Operations & Processing Performance Management Leadership

Program Management Team Management Vendor Management Resource Management

Customer Services Workers Compensation Grievance & Appeals Process Improvement

EXPERIENCES AND ACHIEVEMENTS

EMBLEM HEALTH, New York, NY 2011 – Present

New York's leading neighborhood health insurance and wellness company.

Manager

Supervise the daily operations of Dental claims to ensure timely and accurate claims processing including void/adjustments claims. Oversee staff of 30 Union and Management. Perform trend analysis on claims volumes and inquires to identity processing trends. Coordinate activities between IT/System Support for implementation of new initiatives. Manage, monitor and coordinate activities of various departments to ensure corporate goals are met. Develop, analyze and document policies and procedures that define workflows within the area.

Managed performance in the Dental Department to ensure goals are achieved for performance guaranteed groups.

Achieved corporate matrix by processing performance guaranteed group claims within 10 days with 98% accuracy and 6 days overall.

Reviewed and explored opportunities for process improvements and increased efficiencies.

Created BRD, MRT and Project Proposals to implement new efficiencies or modify existing ones.

INTERNATIONAL BROTHERHOOD OF TEAMSTERS LOCAL 237, New York, NY 2008 – 2011

Largest local in the Teamsters international union (International Brotherhood of Teamsters). Includes 237 Overview, union reps and member services.

Assistant Director

Managed the daily operations of the Welfare Fund and staff. Ensured that all union dues were received and employer contributions were accurately reconciled for the City of New York and its various agencies. Developed process to automate reconciliation of contributions from groups to the Welfare Fund. Maintained communication between large city agencies and the Welfare Fund, which included the City of New York, Health and Hospital Corporation, New York City Housing Authority and the New York City Board of Education. Oversaw Optical and Dental Vendors administering benefits to members. Acted as a liaison to ensure member eligibility is accurate with Pharmacy Vendor, (Emblem).

Managed staff of 17 within the welfare fund and manage employer contributions for Local 237 members (active/retiree).

Installed IVR system in Welfare Fund to automate system service, improved efficiency and customer service.

Improved overall customer services by reducing wait time and call abandonment.

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HEALTH INSURANCE PLAN OF NEW YORK, New York, NY 1993 – 2008

Assistant Director: Financial Recovery, Coordination of Benefits & Adjustments (2000 – 2008)

Managed the growth and profitability of claim dollars identified through recovery of claims overpayments. Provided daily support and directions to the Third Party Recovery, Claims Adjustments and Refund Units. Coordinated internal recovery process while ensuring accuracy of overpayments data and notifications of potential recoveries are done within contractual guidelines. Managed activities of multiple recovery vendors assigned to various recovery types with the organization. Managed, monitored and coordinated activities of the staff to ensure refunds received are processed and completed timely and accurately. Ensured processing system is updated to reflect any changes to professional and/or facility claim payments.

Accurately updated claim data to reflect confirmed over/under payments and maintained coordination of benefits (COB) data to ensure claims are paid in the correct order of benefits.

Coordinated with potential overlaps, issues related to claim investigation, financial reconciliation, data feeds, reporting and invoicing, and ensured cost containment measures are met.

Yielded positive results including a record $12 million recovery project for Defibrillator and other related services.

Improved processes related to overall claims overpayment within the organization which showed annual reduction due to data mining.

Implemented new vendor programs/protocol, processes, procedures and assisted in contract Request for Proposals (RFP) and finalization process.

Manager (1993 – 2000)

Oversaw a staff of 37 nonexempt Union employees and Management employees for second shift claims operations. Shift operations consist of the processing of facility Medicaid and professional claims processing, file room functions and typists.

EDUCATION & TRAINING

Degree, Business Administration, Essex County College, Newark, NJ 1988

Degree, Business, Berkeley College, Newark, NJ

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