Allen Nock

**** *. ****** ***-*** Bernardino, CA 92405

909-***-****

Email: acy4ew@r.postjobfree.com

SUMMARY

An innovative, experienced project manager, with over 25 years of professional management experience in organizing and implementing projects, improving operational efficiency, team building and analyzing business performance to optimize effectiveness and quality of service provided. Progressively approaches dynamic health care challenges, anticipates and plans for industry movement. Quickly assimilates new programs and strategic direction. Extensive knowledge of medical management procedures and regulatory requirements. Able to handle multiple tasks concurrently, while meeting tight deadlines. Experienced with contract negotiations and claims inquiries. Manage office flow effectively. Demonstrated ability to creatively motivate staff to maximum productivity.

PROFESSIONAL EXPERIENCE

Hyperbaric Oxygen Institute, Irvine, CA

Project Manager, June 2013 to present

Responsibility for the successful initiation, planning, design, execution, monitoring, controlling and closure of projects. Areas of responsibility include patient schedule, tracking of quality outcomes, chart management, oversight and maintenance of work flows, policies and procedures, patient communication, medical insurance billing and patient billing.

Kelly Services at The County of San Bernardino

Administrative Analyst, March-May 2013-90day assignment

Perform complex and varied administrative and fiscal work which crosses departmental lines and impacts the County organization as a whole; conduct research and analytical studies and make recommendations for development, implementation or improvement to programs or operations, which may result in new or revised policies or programs. Work performed is confidential, including responsibility for employee relations activities.

SLG Millenium Group at USAA, San Antonio, TX

Life Insurance Underwriter Requirement Manager, 2010-2011

Ensure all state and company requirements are met. This includes confirming insurability; including financial, criminal and medical. Utilize various company and vendor computer programs to determine risk structure. Gather required data by contacting applicant and vendors using various methods, including telephone, email, and written formats.

KCI USA, San Antonio, TX

Senior Claims Representative, 2009-2010

Adjudicate complex managed care and Medicare claims. Ensure insurance contracts, including medical necessity criteria, are upheld. Support other departments including collections, order fulfillment, delivery and clinical review. Interact on phone and in writing with all customers including home care patients, hospitals and SNF's, KCI sales representatives and case managers as well as insurance company clinicians. Educate internal and external customers on policy and procedures, contracts and billing to ensure prompt payment and accuracy. Ensure all customer needs are met and customer is satisfied. Suggest and implement process improvements when appropriate.

Kelly Services, San Antonio, TX

529 Distribution Representative, 2008-2009

Process incoming requests from shareholders requesting distribution on 529 mutual fund accounts. Follow company and SEC guidelines when completing distribution. Answer questions and perform maintenance to accounts

Humana Military Healthcare, San Antonio, TX

Healthcare Finder, 2007-2008

Process incoming requests from military treatment facilities (MTF) for specialty care for the TRICARE Program.

Determine the following: type of care needed, most cost-effective provider, quality indicators, CPT/HCPCS codes,

ICD-9 codes, and length of care. Approve or deny referral based on TRICARE policy/law and notify beneficiary, MTF and selected provider within mandatory timeframes. Accept and resolve customer service calls from beneficiaries.

PacifiCare of Texas/United Healthcare, San Antonio, TX

Claims Manager/OPS Manager, 2005-2006

Manage several areas of the HMO/PPO claim department including; claims production, pricing, member and provider correspondence, auditing and delegated claims oversight. Manage provider phone queue ensuring service levels and abandonment rate are maintained. Coordinated all sponsor and government audits. Responsible for hiring, appropriately staffing, budget, morale, disciplinary action for all above areas. Key contact for all delegated Medical Group claim inquiries as well as internal departments claim inquiries, i.e. Network Mgmt., Healthcare Management. Work directly with Network Management, Medical Services, Marketing and Provider of Service to explain difficult concepts and gain consensus regarding changing workflows and/or policies. Manage work done by outsourcing vendors, CSRG and VBO/Letterkenny, Ireland.

PacifiCare of California, Cypress, CA

Supervisor IV/Team Leader IV, 2001 - 2005

Supervise a staff of 24 employees responsible for intake, research and adjudication of provider driven projects and retro audits. Adhere to and implement company and regulatory guidelines, participate in various quality improvement projects inside and outside operations. Identify root cause of rework, create and implement actions plans, working with other departments, the provider and internally. Work directly with Network Management, Medical Services, Marketing and Provider of Service to explain difficult concepts and gain consensus regarding changing workflows and/or policies. Manage work done by outsourcing vendors, CSRG and VBO/Letterkenny.

Kelly Services at Wells Fargo Home Mortgage, San Bernardino, CA

Research Representative, 2000 - 2001

Investigated and resolved both written and verbal inquiries from customers pertaining to their mortgage accounts. Ensured that accurate information was given regarding nearly every aspect of the customer’s mortgage. Selected by management to become part of the Escrow Recovery Project. Received departmental recognition for achieving a high level of productivity and accuracy. Displayed excellent written communication and listening skills.

Aetna US Healthcare Loma Linda, CA

Auditor/Quality Consultant, 1993 - 1999

Ensure all PMG's (Participating Medical Groups) are audited and in compliance with AHPC, CMS and DOC regulations for delegated claims/member services responsibilities. Conduct site visits in order to ascertain if PMG is achieving compliance in the following areas: staffing, batching controls, claims denial process and denial letter language, claims policy and procedures, timeliness, appropriate tracking of claims and claim inquiries, appropriate reports and member service policy and procedures. Complete written audit suggesting ways for improvement and present findings to Delegation Oversight Committee. Work closely with PMG's assisting them in meeting compliance. Attend JOC's and other meeting with PMG. Assist department in preparing for upcoming NCQA review for accreditation. Back up credentialing and appropriate network auditor.

Oversight includes the following: supervising PMG claims denial review unit, prepare trend reports, prepare CMS reports, track PMG claims timeliness throughout the year.

Team Leader/Administrator of Operations

Ensure excellent service is provided to our HMO customers (members, providers and employees) in a cost-effective manner. Encourage team environment and develop competencies within the team to improve the quality of services, thus contributing to member retention and enrollment. Maintain departmental standards of service excellence; thereby supporting AHPC's mission. Conduct site visits with visiting employer groups/plan sponsors.

Oversight includes the following Senior HMO functions: member services institutionalized member tracking, enrollment and disenrollment of members from Senior Plan (Northern and Southern California), Correspondence Service Team, sorting and distribution of 1000 pieces of mail per day, Member Outreach welcome calls, medical review follow-up, and management of the CMS mandated Working Aged Survey. In addition, claims

EDUCATION –ACHIEVEMENTS - RELATED SKILLS

San Bernardino High School

University of Phoenix US-CA-San Bernardino

Microsoft Office Suite – Advanced User

Bilingual – Spanish, Conversational

MPOWER, HP, EPDB systems

Completed various Skill Path seminars in the fields of Supervisory and Management Development, Human Resources Development, Personal Development and Customer Service Practices.

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