TAMEKA RAGLAND

Highland, CA ***** • addd17@r.postjobfree.com • 909-***-****

PROJECT MANAGER – HEALTHCARE REVENUE CYCLE

Improving Customer Satisfaction & Retention • Reducing Costs & Increasing Revenue Streams

Thirteen years of experience leveraging extensive business acumen and systemic view of organizations to meet diverse business demands and deliver effective change management solutions. Impressive record improving organizational effectiveness and delivering highly successful operational and compliance strategies. Cultivates productive client relationships with Executive leadership, and clinical providers. Recognized for leading top-performing teams to complete business-critical initiatives. Respected for enhancing corporate compliance culture while providing coaching/consultation to professionals at all levels. in addition I have extensive pharmacy and PBM, experience from basic logistics to resolving grievance and appeals.

PROFILE SUMMARY

• Project Management & Account Management • Revenue Cycle Management

• Compliance & Audit / Risk Analysis • Productivity & Efficiency Improvement

• Variable Labor, Financial Analysis & Budget Management • Utilization Review Management

• Client Relations Patient and provider grievance and appeals

• Quality Case Management[1]

• Employee Development & Performance Management • Medical Billing & Medical Terminology

• Recruiting, Hiring, Training & Development • HCPCS & ICD-9 / ICD-10 Coding • SWOT Analysis & Process Mapping / Reengineering

PROFESSIONAL EXPERIENCE

Hospital Business Services Inc

Project Manager, Corporate Business Office 05/2017- Present

Managed the Patient Financial Services Corporate Business Office Division, assisting the V.P. of Revenue Cycle in managing on-going projects for the organization using Agile methodologies, defining project scope, metrics, deliverables, and communicating them to involved parties throughout the project life cycle.

Manage the resolution of patient Complaints and appeals

Manage the resolution If provider complaints and appeals

Directly supervised 20+ employees, across three operational divisions, including Commercial/Managed Care/Medicaid/Medicare payers for AR Billing, Collections, Denials Management, Cash Posting, Credit Balances, EOB Review, Training and Analytics, responsible for approximately $35M in monthly revenue.

Presented to President, Board members, CEO, CFO, and other C-Level executives monthly revenue performance, variable labor, vendor outsourcing, and payer strategies for effective JOC payer meetings.

Process mapping, creating the staffing matrix, conducting interviews

Executed standardization of policies and procedures to remediate previous leadership failures in Personnel Management and AR Operations Management across 45 Prime hospitals.

Managed multiple portfolios including CBO KPI Management (Productivity, Quality, Attendance), CBO Transitions to Local Sites (Saint Mary’s Regional Medical Center), Aged AR Outsourcing (AMCOL, CMRE), Case Management Concurrent Reviews (SMRMC, SRMC) and Corporate Compliance (HBSI).

My abilities to manage increasingly difficult projects resulted in my promotions from Collector to Denials Management Analyst to Project Manager of Patient Financial Services in less than a year.

Grapevine Home Health

Medicare Case Manager 8/2015-4/2017

Managed Medicare Case load of 100+Partnered with knowledgeable nursing staff to obtain medical records and lab results required to meet criteria before submitting prior authorizations to patient’s Medicare, Medicaid, or Commercial insurance payer.

Directly supervised 20+ Nurses

Management experience included managing operations for Medicare & Medicaid business

Increased revenue collections by 40%.

EMQ Families First

Insurance/Contracting Coordinator 11/2013-7/2015

Managed new patient intake, referral processing, claims submission, dispute resolution.

Lead Desktop Procedures Project, documenting S.O.P.s and Job Aids and coordinated staff training with Finance Team throughout Northern and Southern California sites.

Prepares utilization/encounter data reports for use by clinical and billing staff to ensure compliance with service authorization and accurate insurance and client billing

Resolves discrepancies related to encounter data/billing/authorizations

Prepare and work to resolution provider revenue cycle complaint and appeal

Schedules initial assessment and ongoing appointments for all clients/families

Answers phones and obtains all information related to initial request for services,

referral source, basic demographics, and insurance/payment responsibility

Answers questions regarding service availability

Ensures that non-English language needs are met to facilitate effective access Obtains signed hard copy documents required such as HIPPA notifications, ROIs, and payment responsibility

Ensures that client receives all relevant agency information and documents related to services being accessed

Developed audit tool, measurement definitions, policies and procedures and conducted weekly calibration meetings with auditors across multiple state sites.

Collaborated with Finance department to analyze, forecast and maintain program budget.

Proactively communicated with Medicaid and Commercial payer contracting liaisons.

Cultivated productive client relationships with internal and external departments.

Fostered strong rapport with key clinic nurses and physicians to identify dosing adherence barriers.

Implemented the creation of authorization tracking system.

Scan Health Plan

Grievance & Appeals Specialist 01/2013-11/2013

Responsible for managing to resolution complaint/appeal scenarios for all products, which may contain multiple issues and, may require coordination of responses from multiple business units.

Ensure timely, customer focused response to complaints/appeals. Identify trends and emerging issues and report and recommend solutions.

Provided written communication to the member that is clear, concise and professional in appearance, addressing the concerns submitted by the members. Typing and knowledge of computer system.

Maintained case file documentation in accordance with Medicare criteria and internal clinical policy and procedures. Must coordinate/gather appeal case files with appropriate clinical documentation, and Medicare regulations used to make a peer defensible argument related to coverage.

Maintained Medicare compliance on all case files assigned.

Consistently maintained a 95% or higher on internal and external audits in accordance with Medicare Compliance standard

Aetna Health Plan

Grievance & Appeals Specialist 10/2007- 8/2010

Consistently maintained a 95% or higher on internal and external audits in accordance with Medicare Compliance standard

EDUCATION

Bachelor of Health Care Administration Kaplan University

60 Credit Hours Completed

Certification- National Certified Pharmacy Technician PTCB.org

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