Quality Assurance Medical

Objective

To establish employment within a company offering a professional environment and providing the opportunity to obtain skills leading to career advancement within its structure.

Experience

12/2014-9/2016

MetroPlus Health Plan

New York, NY

Assistant Director/Complaints Manager

Create & maintain reporting both weekly and monthly for executive management review.

Create, maintain, & present all complaint reports for submission to regulatory agencies and committee members/meetings on a quarterly basis.

Tracking and trending of all complaints for both internal/external reporting purposes.

Develop all complaint materials training materials and provide process updates/changes as they occur

Ensure that all complaint files and logs are maintained up to date

Conduct and initiate internal/external investigations ensuring all complaints are handled efficiently and within appropriate time period

Review all formal complaint acknowledgement and resolution letters created by Complaint’s Team Leader and Complaints Coordinator

Review existing complaint tracking systems recommending edits/upgrades to ensure that all call criterion is appropriately/efficiently identified and reported.

Ensure that all Customer Services Representatives are being properly in-serviced/trained on proper handling and identification of all complaints

Directly responsible for a staff of 5+

01/2012-12/2014

Theradynamics Physical Rehab

New York, NY

Outpatient Medical Billing Operations Manager

Manage and refining the work flow for the billing, appeals & grievances, collections, AR, medical records, and credentialing departments for 7 physical therapy office locations.

Executing any and all tasks pertinent to the growth of the company including but not limited to: time cards, performance reviews, daily production reports, daily and monthly statistics and analysis of accounts receivable, claims, and denied accounts. Adjusting any unrecoverable amounts.

Created over 50 dispute/appeals, collections, and medical record templates. Creating department and process manuals.

Conducting meetings and training groups, and assisting in the determination of continued treatment.

Correlating with the front office and physical therapy’s supervisors to create an efficient work flow process to decrease annual adjustment amount.

Observing operations to identifying and providing solutions for day to day processes.

Successfully increased accounts receivable by 20% in 6 months.

Preparing, conducting, and monitoring audits

Credentialing and recredentialling all outpatient physical therapist.

Assisting in CAQH and NPI requests.

Directly responsible for a staff of 5+

03/2010-01/2012

Optum Health- BCBS MH/SA Division (UHG)

San Diego, CA

Sr. Appeals and Grievance Coordinator

Administratively resolving member/ providers correspondences.

Providing expertise or general support to teams in reviewing, researching, investigating, negotiating and resolving all types of appeals, disputes and grievances.

Analyze and identify trends for all appeals and grievances. Researching and administratively resolving written Department of Insurance complaints and complex or multi-issue complaints submitted by consumers and physicians/providers.

Compiling resolution letters for both administrative and clinical reviews.

Granting authorizations for pre services or continued services.

Preparing, conducting, and monitoring audits

10/2005-02/2010

Johnson & Rountree Premium

Del Mar, CA

QA Director & Audit Coordinator

Daily task include but are not limited to: Assisting medical providers with overpayments, complaints, provider relations matters, collection / recovery, and appeals & grievance issues.

Providing necessary training of: system, medical insurance billing policies, and proper call handling.

Oversaw all quality assurance matters such as: monitoring representatives voice messages, emails, system entrees, test scores, and calls. Assembling and providing collector’s audits and review reports. Compiling, administering, and scoring training.

Creating department and process manuals and reference guides.

Completing I9 forms for past and present employees.

Developed and maintained a dispute tracking and resolution system

Directly responsible for 3 appeal representatives and supervised 60+ employees

Education

11/2001

Cherry Creek Prep HS

Aurora, CO

High School Equivalence Degree

High School Equivalence Degree Achieved 11/01

08/2013 CrossCountry Education

HIPAA and Medical Records Law Course

Emphasis in computer science, marketing/ business, psychology and criminology

Completed multiple Medicare webinars.

Skills

Emdeon Portal

COSMOS / FACETS

MS programs (excel, etc)

Crystal Reports

ISET

Employee Training

IDARS,TDARS, ODARS

CPW

Quality Assurance Auditing

EDSS, LINX, RTMS

MEDISOFT

Statistics and business analysis

Grievance

Insurance Policies

Refining Workflow

Provider Relations

60+ WPM

Overpayment Recovery

REDOC

Operations Mngmt

Appeal/Dispute Resolution

Multiple Line Operation

Organized

Multitasking

Medisoft

HIPPA Guidelines

Problem Solving

UNET

Management

Medical Terminology

Project Management

Medical Billing

Negotiating

Detail Oriented

Credentialing

Financial Reporting

References are available on request.

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