Monica D. Wise

**** ******** ****** § Westland, MI 48186 § ' 734-***-**** § * acy55w@r.postjobfree.com

Risk Adjustment / Hedis Specialist / Business Analyst / Quality

Energetic, resourceful, and results-driven professional with exemplary qualifications and experience to lead and support functions requiring communication, problem solving, relationship building, and leadership abilities. Work effectively independently and collaboratively as part of a team in demanding fast-paced environments to accomplish business, financial, and quality objectives. Self-motivated individual with well-developed interpersonal skills to establish productive working relationships with patients, providers, team members, and all levels of management.

Areas of Strength

§ Healthcare/Patient Care Operations § Regulatory Compliance & Quality § Staff Supervision/Development

§ Internal and External Relationships § Healthcare Systems / Technology § Resource Planning / Allocation

§ Insurance Claims/Medical Records § Policies/Procedures Development § Coding and Compliance Audits

§ HEDIS/Performance Measurements § Billing / CPT and ICD-9 Coding § Handling / Resolving Problems

Professional Experience

HICS Analyst, BCBS(Optech, Detroit MI 11/2016- 3/5/2017

Responsible for reviewing and responding to complaints and inquiries received from the Health Insurance Marketplace regarding enrollment, coverage, and billing within a 3-14 day timeframe depending on the level of case.

With general guidance and coaching provides analytical support to a specific group of customers on business applications, infrastructure and technology related activities.

Acts as a project team member, specifically on requirements definition and testing activities.

Provides guidance, assistance, coordination and follow-up on complex problems and ensures resolution within a specific timeframe.

Works with application developers and operations personnel to support production application and customer specific operations.

Knowledge of HICS Database,Metadvance, 834 File Database,NCSW and Client Manager

Office / Practice Manager, Pediatric Associates, Dearborn, MI 2015 – 2016

Fully responsible for using strong leadership and communication skills to supervise day-to-day operations of the practice. Charged with hiring, scheduling, evaluating, and managing non-physician employees, serving as liaison between physician and staff, maintaining medical records and files, and handling billing, coding, and collections.

Ensure the front and back office is maintained, orderly, efficient, friendly, inviting, and secure for patients and their families. Create, update, and enforce office policies and procedures as needed to achieve practice goals.

Interact and provide assistance to individuals in a respectful manner that takes into account their special needs, physical abilities, and age. Ensure team members have positive and professional communications with patients.

Tactfully handle a wide range of employee relations and personnel issues including counseling and disciplining staff as needed, resolving any problems, and training individuals in job duties, processes, and procedures.

Accept payments, complete encounter form/router, oversee billing procedures, type medical information for chart and correspondence relative to patient care, and communicate with insurers and physician group reps.

Directly responsible for all aspects of office maintenance, coordinating efforts with landlord, maintaining office supplies, inventories, and equipment, and overseeing MU, OSHA, CLIA, PCMH, and HIPPA compliance related issues.

Ensure and maintain a relationship BCBS, HAP, MOLINA, MERIDIAN and a host of healthcare insurance companies, so I can stay updated on all processes and implement in the office.

QI Specialist / MSR II, Molina Healthcare, Inc., Troy, MI 2014 – 2016

Direct responsibility for applying focus, attention-to-detail, and organization and communication skills to collect medical records/reports from providers based on needed service reports, compilation reports, and gaps and load data into Palantir. Worked with HEDIS team to monitor accuracy of records and provide data collection/reports.

Demonstrated strong knowledge of policies and procedures and applicable regulatory requirements to accurately, efficiently, and courteously respond to incoming telephone calls from both Molina members and providers.

Ensured HEDIS measures were addressed and documented, assigned providers for CSHCS, accurately recorded calls in QNXT system, and provided members with information regarding Dual Options and MI Health Link.

Completed duties with minimal supervision, handled time sensitive and confidential information with discretion, managed daily workflow, established priorities, and ensured the timely completion of all projects and tasks.

Maintained accountability for ensuring professional and courteous communications, demeanor, and interactions with individuals at all levels while continuously seeking ways to provide value-added assistance/support.

Professional Experience (Continued)

Office Manager / Medical Assistant, St. John Providence Health System, Southfield, MI 2009 – 2015

Held accountable for demonstrating initiative, problem solving and coordination skills, and excellent leadership abilities while providing planning and direction to the Internal Medicine department. Ensured structures, systems, competencies, and values were developed and executed to maintain a high level of efficiency and patient service.

Acted as a resource to senior management and staff for research, development, operational initiatives, training, and troubleshooting and as a liaison with team to identify and resolve claims processing and other problems.

Ensured compliance with third-party payer contracts and managed care guidelines, maintained external relations, and performed functions related to patient care, registration, billing, scheduling, records, and audit/chart reviews.

Displayed exceptional capacity to meet deadlines, build rapport with individuals at all levels and backgrounds, and to support business and department goals by promoting a positive environment that exceeded objectives.

Recognized by management for anticipating problems, presenting effective solutions/recommendations, team collaboration and leadership, exceeding work expectations, and consistently delivering outstanding results.

Medical Assistant Team Leader, Briarwood Family Medicine, Ann Arbor, MI 2007 – 2009

Leveraged leadership and communication skills to manage day-to-day office operations including preparing clinic for site reviews and audits. Developed, implemented, and managed plans to improve HEDIS performance scores, implemented policies and procedures to comply with regulations, and trained, developed, and evaluated staff.

Monitored HEDIS performance and reported results, outcomes, and progress to Senior Management and worked directly with various Health Plan Provider Service Representatives on quality performance bonus measures.

Reviewed patient accounts for accuracy, audited coding to ensure claims were being billed appropriately, and identified and provided additional assistance as needed to support efficient and productive office operations.

Accepted new responsibilities with a positive, cooperative, and team-oriented attitude, completed all projects and tasks in the most efficient manner possible, and exhibited excellent time management and multi-tasking skills.

Accurately maintained files, documents, systems, and reports to provide highly reliable information quickly and utilized strong interpersonal skills to respond effectively to both internal and external requests and inquiries.

Education

Associate of Arts in Health Care Administration, University of Phoenix, Phoenix, AZ (GPA: 3.74)

Training: Medical Assistant Diploma (National Institute of Technology), Medical Assistant Certification (AMT)

Computer: Microsoft Office Suite, Healthcare Systems, EMR/EHR, Analysis, Reports, Research, PCs/Windows

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