Project Management Quality Control

Dear Sir or Madam,

Please accept this e-mail as an introduction for the open healthcare operations leadership position within your organization. Attached please find my resume that details my extensive healthcare management skills. I have been afforded Sr. Management oversight responsibilities within healthcare claims operations, including but not limited to; project management, quality systems; root cause analysis, fraud, waste and abuse detection, risk and quality control. I am confident that with my expertise I can be an asset to your organization. I look forward to discussing opportunities that may align with your needs. I am looking forward in making a difference in your organization.

Respectfully,

Sabrina Ricks

Qualifications

Specializing in identifying escalated issues and providing rapid resolution.

Extensive knowledge in Claims Operations, Claims Audit, and Provider Dispute Resolution.

Experienced Team Leader with a diverse staff and various levels of claims experience.

Subject Matter Expert for commercial group, Government (Medicare and Medicaid/Medi-Cal) and ACA healthcare products.

Excellent communication, presentation, and team motivation skills.

Excellent knowledge of medical terminology and CPT, DRG, APR-DRG, MS-DRG and ICD10 Coding.

Excellent knowledge of CMS requirements, State and Federal regulations, rules, and guidelines.

Detailed in conducting research, strong analytical skills and interpretation of benefits and contracts.

Successfully prepared for and presented in multiple State and CMS audits.

Coordinated initial and ongoing of staff related to claims adjudication and quality.

L.A. Care Health Plan

Los Angeles, CA

August 2016-Current

Claims Manager- Audit

Management of the Claims Audit department.

Implementation of audit processes.

Liaison between claims, internal and external business partners.

Process improvement specialist.

Expert in Staff development and motivation and retention.

Specifically requested by the Chief Operating Officer to build out a claims quality system and team.

January 2015-August 2016

Claims Operation Supervisor

Supervisor-Medi-Cal Claims Production

Management of daily claims inventory

Consistent staff development

February 2013-January 2015

Claims Training Specialists

Provide training and development for new hires in claims department.

Contribute to ongoing training and development of veteran staff members.

Development and implementation of training material for new and existing claims processing.

Provide valuable feedback to the Management team as it relates to development and progress of new and veteran claims examiners.

Provide ongoing training to contracted third party service vendors.

Maintain awareness of changes in the industry and provide claims staff with updated information as it relates to our day-to-day operation.

November 2011-Februrary 2013

Claims Quality Auditor

Performed monthly quality audits for the claims adjudication team.

Performed quality audits for all high dollar claims reimbursement.

Assisted with day-to-day oversight of claims compliance standards.

Developed the process to control duplicate provider payments.

Citizens Choice Health Plan

Cerritos, Ca

August 2007- November 2011

Senior Claims Auditor

Assist in the supervision of Medicare Claims Department.

Responsible for monitoring claims workflow including distribution of workload, monitoring inventory for aging and regulatory compliance.

Responsible for weekly check and remittance advise.

Liaison between Contracts/Provider relations, Quality Management and Utilization Management departments

Audit all claims for payment, and coding accuracy.

Conducts external Claims Compliance Audits with contracted Independent Physician Associations and Medical Groups.

Resolution of escalated provider inquiries, and provider dispute resolution.

Lakeside Healthcare Inc

Glendale, Ca

June1997-August 2007

Lead Compliance Auditor

Assist in the supervision of daily function of commercial claims unit.

Prepare and report monthly timeliness percentages to contracted Health Plans.

Schedule, prepare and present all audits conducted by Health Plans.

Expertise in determining back-log issues and turnaround workflow specialist.

Created, developed, and implemented auditing tools pend tools and Provider Dispute Resolution (AB1455) policies.

Provide feedback to claims leadership regarding training needs based on quality review audits.

Review of system generated reports for claims payment accuracy before and after check distribution.

Claims examiner Level III, adjudication of all specialty claims and appeals.

HealthNet

Woodland Hills, Ca

October1995- June 1997

Member Service Representative Level II

Served as a liaison between Health Net members, employer groups, and providers.

Assisted representatives with issues that require a high level of skills and knowledge of Health Net policies and procedures.

Network representative with the IPA’s & MSO, contracted physicians, contracted hospitals.

Responsibilities include developing and maintaining positive customer relations, coordinating with various functions within the company to ensure customer requests and questions are handled appropriately and in a timely manner.

Research and analysis of data to address operational challenges and customer service issues. Received and placed follow-up telephone calls / e-mails to answer customer inquiries. Used systems for tracking, collecting information and troubleshooting.

Reference upon request

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