Health Plan Subject Matter expert
Resume:
MARGARET A. DEARLOVE
Cell 845-***-****
Middletown, NY 10940
****************@*****.***
PROFESSIONAL HIGHLIGHTS
Over 25 years of administrative, healthcare, and executive experience.
Exceptional knowledge of business practices including, group and individual membership, customer relations and administrative procedures.
Extensive analytical and problem-solving skills.
Excellent communication and interpersonal skills.
Demonstrated ability to handle diverse situations under strict deadlines.
Exceptional ability to implement policies and procedures according to state and federal guidelines.
Demonstrated ability to handle compliance issues.
PROFESSIONAL EXPERIENCE
Cognizant Technology Solutions
New York, NY
Membership Manager, Senior Subject Matter Expert 2 016 - Present
Document and train team on client business processes
Support team with all areas of membership
Subject Matter expert for health plan and client
Provide mapping documentation for system migration
Analyze results of reconciliation and provide direction to the team
Document all policies and procedures as it pertains to membership
Liaison between the health plan and the client
Provide accurate and timely responses for all compliance inquiries
Emblem health
New York, NY
Assistant Director, Enrollment 2003 – 2016
Direct the analysis of all proposed new business changes to determine the impact on existing systems and recommend changes/enhancements as required
Develop and maintain the automated enrollment systems and analyze the business needs for system support and enhancement.
Plan and direct the decision and development of new enrollment systems or enhancements to existing system including reviewing, analyzing and evaluation of all related systems.
Establish and maintain work standards for all functional positions, monitor workflow, identify inefficiencies, and recommend solutions
Ensures efficient and timely enrollment processing by reviewing and analyzing workflow, modifying procedures as required and setting priorities and objectives for assigned staff.
Involved in system conversion; write business requirements, develop test plans, analyze error reports ensure all data is converted appropriately.
Assist in directing the creation of new and existing groups onto the Electronic Data Interface system.
Hire, train, counsel and supervise staff in the performance of their work.
Prepare and/or analyze reports on enrollments, terminations, changes, and error reports.
Health Insurance Plan of New York – HIP
New York, NY
Manager, Enrollment 2001 - 2003
Supervised 20 enrollment specialists that were responsible for timely and accurate enrollments, disenrollments and changes for New York City and Commercial members, which accounted for 65% of the company membership.
Acted as the liaison between The City of New York Office of Labor Relations, Third Party Administrators and New York State Department of Insurance.
Validated the data transmitted from The City of New York Office of Labor Relations.
Responsible for all Q-care table updates as it pertains to Health Codes, Union Welfare Funds and Employer Groups.
Responsible for the reconciliation of all New York City and commercial membership files for enrollment and billing departments
Oversaw payroll utilizing a payroll service interface program, including timesheet approval, calculation of weekly hours for each employee, and maintaining personnel files
The Bronx Health Plan - Affinity Health Plan
Bronx, NY
Member Administration Supervisor 2000 – 2001
Supervised data entry and resolution specialists to ensure timely and accurate enrollment of Child Health Plus and Medicaid members.
Responsible for data integrity by overseeing of quality management program
Acted as the liaison between outside agencies Maximus, New York State Department of Social Services and Department of Health.
Accountable reconciliations as required by the Department of Health.
Established and implemented policies and procedures to ensure accurate departmental workflows.
Creation and generation of monthly Child Health Plus reports, such as enrollment/disenrollment, quarterly reports, billing to members and state.
Oversaw all phases of the facilitated enrollment process.
Westchester Prepaid Health Services Plan, Inc.
Tarrytown, NY
Enrollment Manager 1995 - 2000
Implemented all policies and procedures governed by state and federal guidelines as it pertains to the Enrollment department
Instrumental in the increase of membership due to institution of a member retention program, and excellent customer service
Over a three-year period, successful reduction of Child Health Plus quality errors from 85% to 5% during New York State Department of Health annual audits.
Responsible for all enrollment tasks governed by our membership database.
Supervised enrollment staff to ensure a smooth workflow.
Established an employee cross training program to ensure uninterrupted workflow.
Acted as liaison between outside agencies New York State Department of Health and Department of Social Services
Oversee the day-to-day functions of Medicaid and Child Health Plus enrollment department.
Responsible for reconciliation of member eligibility roster.
EDUCATION
M.B.A. - Master of Business Administration, 3.91 GPA
Nyack, NY
Nyack College 2004
COMPUTER SKILLS
Microsoft Word, Excel, Access, PowerPoint, Visio, Enterprise Project, and Portfolio
Management
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