Summary

Deep expertise in healthcare including billing, appeals and grievances, revenue cycle, provider services, and member services. Background in quality improvement, personnel management, and healthcare regulations. In depth understanding of member services inquiries, front end procedures, charge capture processes, insurance billing, and CMS and Medicaid payer guidelines. Key skills include:

Quality Improvement

Operational Audit

Personnel management

Healthcare Regulations

Professional History

HCSC/Blue Cross Blue Shield of Illinois-Manager Illinois Medicaid Operations

July 2019-Current

Timely resolution of State Complaint Management and Work

Defect Management and Tracking (95 Defects YTD)

Claims Production Oversight

Claims Regulatory Reporting

UAT Testing

External Audit Management Impacting Claims/Disputes

Fee Schedule Execution Oversight

MAR Control Oversight Testing

Provider Dispute Quality Review

Claims Quality Reviews

Host Weekly Workgroups internal and external stakeholders

Claims Rejection Monitoring and Oversight

Regular Oversight and Coordination with Shared Service (PASS)

State Account Manager Operational Contact

P&P Management for Operations

Robert Half-Consultant Firm

HealthFirst-Senior Analysis Medicare Advantage Appeals and Grievances (Contractor)

February 2019-July 2019

Quality Reviewed Medicare Advantage Member Appeals and or Grievances

Determined Case Outcome (Appeal or Grievance)

Confirmed if Appeals were reviewed and resolved timely

Ensured that Adverse Determination Letters were sent to member and member Authorized Representative

Confirmed if the correct letters were generated for the right Line of Business

Confirmed if Appeals and or Grievances were within or out of compliance

Made recommendations to Leadership on Appeals handing

Produced weekly scorecards on the Appeals & Grievances Coordinator overall performance

Trexin LLC-Consultant Firm

Bright Health Plan-Director, Appeals and Grievances (Contractor)

November 2018- February 2019

Oversaw the activities and management related to denial inventory, ensuring processes are performed efficiently, effectively and accurately within all established operational and SOX guidelines.

Established controls and review mechanisms for SSC policies and procedures.

Ensured timely submission of appeals and liquidation of denials inventory.

Provided support and guidance related to the Denials Management Action Teams (DMAT)

Monitored, trend and communicate with SSC Leadership, Case Management, Denials Managers, and Facility Leadership regarding denial trends, new denials and final write off denials identified via EDW, Visual Insight Dashboard, Vista, and other denials tools reports.

Demonstrated strong commitment to stakeholder relationships by taking ownership of issues and facilitating effective outcomes in a timely manner.

Understood and communicate contract specific issues related to the resolution of disputed payments, discount and allowance calculations for a variety of payers such as Medicare, Medicaid, HMOs, PPOs, IPAs, employers, etc.

Followed escalation protocols to include Attorney, Corporate Dispute Resolution, Strategic Pricing and Analytics, and Corporate Payment Compliance.

Participated in Joint Operating Committees (JOC) with payers, ensuring partnership in inventory resolution.

Oversaw all reconciliation activities for inventory.

Monitored trends and communicate significant shifts in market or operating conditions to SSC and facility leadership.

Identified and implement process improvement initiatives that reduce cost and improve performance.

Evolent Health - Director, Operational Audit, Funding & Recovery Controls

January 2016 – August 2018

Managed all operational audit functionality focusing on core administrative functions and systems (i.e., claims payment system).

Defined and ensured departmental and corporate goals related to client and process audits were met.

Led efforts for defining processes, workflows, methods, tools, training, and expected outputs to support audit best practices.

Oversaw development of audit processes.

Provided recommendations on development and design of new system logic to support legislative activity, medical policy changes, and reimbursement methodology changes.

Oversaw quality assurance activities and audit procedures.

Established and maintained service levels including audit procedures to measure results against goals.

Coordinated identification, prioritization, and resolution of issues with various business areas and vendors.

Developed tactical plans to improve processes and systems.

Assumed leadership role in initiating and completing projects related to increased efficiencies, productivity, and quality for operational functions.

Worked with executive leadership and human resources to evaluate role definition, levels, and career paths.

Molina Healthcare Inc. – Manager, Member Appeals and Grievances and Provider Disputes

June 2014 – January 2016

Built the Appeals and Grievances team from the ground up. This was a 10-12 person team.

Leveraged the TriZetto QNXT platform for Illinois members.

Responsible for the Illinois Medicare and Medicaid Alignment Initiative (MMAI) designed to improve health care for dually eligible beneficiaries in Illinois.

Monitored provider claim disputes and provider claim reconsiderations to ensure review and resolution within 30 days.

Submitted KPI detailed monthly reports to Corporate, identifying the # of Appeals and Grievances received, by membership and category.

Submitted KPI detailed quarterly reports to the State, identifying the # of Appeals and Grievances received, by membership and category.

Monitored provider PSV queue in flight claims, assuring that Medicare and Medicaid claims were processed in allotted time.

Standardized claims productivity and accuracy metrics.

Implemented multiple workflows related to exceptional provider claims reconsideration list, inventory log, and adjustment log.

Provided detailed aging reports on number of days claims were aging.

Submit KPI detailed monthly reports to Corporate, identifying the # of Appeals and Grievances received, by membership and category

Submit KPI detailed quarterly reports to the State, identifying the # of Appeals and Grievances received, by membership and category

Sinai Medical Group – Physician Billing Manager

July 2001 – June 2014

Responsible for charge capture of millions of dollars per month.

Supervised performance of client account billing and collection activities.

Reviewed and accessed the weekly unbillable report.

Addressed concerns and inquiries of clinic managers, hospital staff, patients, and insurance companies.

Conducted random audits of billers’ productivity to assure accuracy.

Reviewed cash reconciliation to encounters.

Trained physicians on full charge capture in Patient Keeper and NextGen EPM.

First Health – Team Lead/Member Services Supervisor

November 1997 – June 2001

Reviewed the calls of staff to ensure accuracy.

Monitored schedule, time, and attendance for 24/7 call center.

Implemented new policies and procedures and assured staff adherence to policies.

Conducted product demonstrations to prospective clients.

Conducted monthly staff meetings.

Trained new and existing employees.

Software Applications:

NextGen, E-Care, Nebo, Passport, Gateway, LSS, Meditech, PCI, Patient Keeper, Boston Workstation, Microsoft, Word, Windows XP, Window Vista, Power Point, Safari, Windows 8, Nextgen, Pivot Tables (Excel Spreadsheets), Interqual, QNXT (Trizetto), Encoder Pro, Grievances and Appeals, Claims Viewer, Emdeon, Aldera, SelectCoder, Workday, Loomis, Onvida, Genelco, Member Hub, HICS, HPMS, CTM, DMS, and Facets.

Education:

Truman College (1987-1988)

Illinois State University (1986-1987)

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