SEKEITHIA V. MOYE

EXPERIENCE

****-*******

Manager, Claims & Network Operations Centene, Corporation

Manage the Claims Liaison and Provider Data Management department and staff.

Function in the capacity of the claims payment expert for the Plan and as a liaison between the plan, claims, Medical Management Department, Corporate Finance and providers to effectively identify and resolve claims issues by way of various systems OPTUM 360, Amisys

Partner with others in Provider Services/Relations who identify and resolve claims issues, and provide instruction to providers’ billing staff and services regarding claims submission policies and procedures to insure prompt and accurate claims adjudication.

Manage the Claims Liaison department and staff and provide expertise to staff to assist in claims issue resolution.

Prioritize work volumes on a daily basis.

Provide Health Plan management with all necessary data to allow for expedient resolution of claims issues & support Health Plan management at all times.

Coordinate documentation, tracking and resolution of all plan providers’ billing and payment issues including IHCP providers.

Provide expertise and research verbal and written providers’ claims inquiries from plan and corporate staff.

Provide expertise to Provider Services/Relations in the identification of Medical Management authorization issues and trends.

Utilizing knowledge of provider billing and claims processing, directs Provider Services/Relations with the claims reprocessing notification.

Track trends in claims processing issues and assist Claims Department in identifying and quantifying issues along with reviewing Claims Department work

Support business initiatives through data analysis, identification of implementation barriers and user acceptance testing of various systems

Identify and analyze user requirements, procedures, and problems to improve existing processes

Perform detailed analysis on multiple projects, recommend potential business solutions and ensure successful implementations

Identify ways to enhance performance management and operational reports related to new business implementation processes

Coordinate with various business units and departments in the development and delivery of training programs

Develop, share, and incorporate organizational best practices into business applications

Diagnose problems and identify opportunities for process redesign and improvement

Formulate and update departmental policies and procedures

Serve as the subject matter expert on the assigned function product to ensure operational performance.

2018-2019

Accounts Receivable Manager MTI A Workers' Compensation Ancillary Solutions Provider / Pompano Beach, FL ( Remote)

Manages subordinate staff in the day-to-day performance of their jobs

Ensure that all associates are appropriately trained to perform their related job tasks and consistently meet established production standards

Assures timely collection of monies due to the company

Manages cash application making sure all cash receipts are applied properly

Maintains Customer Accounts and database; reconcile any outstanding AR issues

Ensures that project, department milestones and goals are met

Ensures accurate receivable records and verifies outstanding account balances.

Address customer inquiries in a timely manner while maintaining a professional and polite demeanor. Ensure the issue is addressed and resolved appropriately.

Review A/R aging weekly to monitor invoicing totals, cash receipts, and invoice adjustments and address any potential concerns or issues.

Ensures that all AR team related processes are accurately documented and accessible to all associates

Creates, and monitors associate production standards to ensure that each associate is meeting those standards

Provide timely feedback to Operations regarding processes or on-going issues that impact the team’s ability to effectively collect outstanding invoices

Ensure that all sales inquiries are addressed and responded to in a timely manner

2016-2018

Supervisor Network Operations AmeriHealth Caritas Palm Beach Gardens, FL

Manage a staff of with 10 Associates

Manage Recovery Projects, responsible for handling third party liability for all Lines of Business of COB, Subrogation, TPL and Cost Containment thus eliminating or minimizing payout when another person is liable. Thoroughly documents findings *within the required timeframe and takes steps to resolve issues, clearly stating the facts so that any other plan representatives can communicate directly with internal/external clients, attorneys, providers, members, insurance companies and state agencies about the same matter. Responsible for handling the processing of all checks received for COB, Subrogation, TPL and Cost Containment including complex, problem-solving situations of checks within the required timeframe

Act as liaison between client and technical solutions/ support groups, using strong communication skills to elicit, document, analyze and validate business processes, systems, and solution requirements Research, identify and specify solutions to problems. Support and conduct user experience, and configuration elements of solution design. Document requirements specifications using high-maturity methods, processes and tools. Support requirements management and change management processes. Consider the business implications of the application of technology to current business environment

Directly responsible for the interviewing, hiring, training, scheduling and monitoring of staff as well as all aspects of A/R Management and Performance Management.

Improved customer relations by reviewing and responding to provider and ACHA complaints in a timely manner (deadline-60 days) to maintain and increase customer satisfaction

Organize and administer weekly claims meetings with providers, account executives and staf.f

Directly responsible for Improving quality by maintaining current knowledge of processing rules, contractual guidelines, plan policies and operational procedures to effectively provide technical expertise to providers

Directly responsible for quickly assess ACHA and provider complaints, diffuse escalated issues, and follow-through (unfailingly) to resolution

2015-2016

Patient Account Supervisor Conifer Health Solutions Tenet Health Boca Raton, FL

Manage a staff of with 12 Associates

Responsible for all aspects of the day-to-day supervision and leadership of Patient Account Representatives, including but not limited to the Performance Management metrics of collections, productivity, quality and aging. Interview candidates and make hiring recommendations and decisions. Complete monthly quality evaluations.

Monitor staff scheduling and adherence to time and attendance protocol. Responsible for all aspects of A/R Management, including but not limited to maintaining workload balance, ensuring maximum efficiency, eliminating rework, and reducing cost. Promptly identify issues and develop action plans to mitigate or resolve.

Train, develop, motivate and assist subordinates in reaching new levels of skills, knowledge and attitude. Effectively maintain a work environment which stimulates and motivates the morale, engagement and growth of subordinates. Identify performance deficiencies and opportunities and implement action plans as needed.

Review and respond timely to requests, including emails, telephone calls, issues, account research and resolution as needed by staff, management and clients. Timely completion of accounts referred to the Supervisory Desk by staff or management.

Directly responsible for the interviewing, hiring, training, scheduling and monitoring of staff as well as all aspects of A/R Management and Performance Management.

2012-2015

Manager of Operation/ Manager, Health Care Organizational Excellence Sutherland Healthcare Solutions, Clifton, NJ (Remote)

Manage a staff of with 32 Associates (Claims, PDM, and Credentialing) to educate on appropriate changes to policies and/or practices pertaining to their job functionality.

Maintain current knowledge of healthcare billing laws, rules and regulations

Serves as a Line of Business SME for accreditation ( URAC)

Act as Liaison in conjunction with my manager between inter- and intra- departments, clients and offsite employees

I Provide and mentor my team, providing positive and constructive criticism and support so they are confident and feel well equipped to complete their stated objectives

I Provide direction and guidance in work assignments

I Provide guidance and leadership for my staff to ensure they are achieving customer satisfaction through effective communication, problem solving, professional phone etiquette and efficient processes.

I manage and oversee multiple Clients while ensuring my requirements are met

I review all A/R and Client Issue’s by vocally communicating issues that may be hindering cash collections on my

I review all A/R and Client Issue’s by vocally communicating issues that may be hindering cash collections on my weekly calls to the client

ATB'S are reviewed and proper staff distribution (ensure that the ATB is distributed exactly how the staff should work the accounts ie, sorted by payor, aging, high to low dollars etc).

Provide timely coaching and feedback to staff

Communicate, respond and deliver excellent customer service to providers and account-executive account managers and other departmental staff inquiries.

2006-2011

Billing Coordinator /Training Specialist / Supervisor – Morristown Memorial Hospital

Manage a staff of 6 billing clerks and secretaries in the Billing Department within the Dialysis Unit

Maintain charts in proper working order in accordance with Federal and State standards.

Ensure all required forms are filled out and in the appropriate section of the patient chart.

Ensure that the medical record’s contents are in proper order and labeled appropriately.

Participate and conduct regularly scheduled chart audits according to predetermined schedule.

Educate staff on medical record standards and/or policies.

Participate and conduct regularly scheduled chart audits including

SQL-Ensure that all SQL requests are processed in a timely and efficient manner.

UAT testing

Create scripts for ADT/PFS special projects utilizing Reflection or Boston Workstation. Aid in the identification and implementation of ADT/PFS system processes that can be automated through scripting.

Ensure the successful implementation of any new PHS/ADT/PFS IT systems or enhancements/changes.

Maintain a thorough knowledge of the PHS/ADT/PFS IT systems and any subsystems and the integration that exists between them and the other hospital I/S systems. Subscribe to system email list servers to be proactive in increasing knowledge and

Keeping abreast of current issues relating to the PHS/ADT/PFS IT systems.

ado4v5@r.postjobfree.com

Medassets

Emdeon

Jiva

I-Health

Florida Medicaid Portal

EXP Macess EDI System

SSI Billing System

Achieve/Path Links System

Invision Billing System

Care Medic Billing System

HMS

Microsoft Office

Lotus Notes 123

Chartmaxx 4.1

OneSource Passport

Epremis billing

Home Care Billing

ADP

Healthquest

Performed User Acceptance Testing UAT)

Amisys

CenProv

TruCare

Portico

EDUCATION

Essex College, Newark, NJ September 1994 - May 1996

Business Curriculum

PROFESSIONAL QUALIFICATIONS

Inter Company: Medical Claims Examiner

Inter Company: Yellow Belt ( Six Sigma)

Licensed Cosmetologist

Community First Aid and Professional CPR

Expertise PPO, HMO, BCBS, Medicare and Medicaid Billing

Nursing Home Billing

McKesson HBOC STAR Trainer

McKesson PHS Scheduling Trainer

REFERENCES

Available Upon Request**

862-***-****

17109 Delaney Drive

Concord, NC 28027

OBJECTIVE

To improve the performance of an organization by clearly defining objectives that are agreed to by both management and employees.

AREAS OF EXPERTISE

Organizational skills

Revenue Cycle Management

Excellent Communication

Detail oriented

Medical Billing

Medical Coding

Insurance Appeals

Payment Posting

Medicare Guidelines

Insurance Collections

HIPAA and PHI Compliance

ICD9, ICD10& CPT Coding

Horizon Meds Manager

Access 1MD

AMI

Medical Records Transfers & Transcription

Computerized Billing Systems

Referrals manual/electronic

Epic Resolute Prelude Cadence billing systems

McKesson HBOC STAR Trainer

McKesson PHS Scheduling Trainer

Reducing AR days from 140 to 36 days

Third Party Billing/electronic/collections

Revenue Cycle Management

Kronos 6.1

On Demand

VI Web

Ace( Automated Collection Environment)

Facets

OPTUM 360 Solutions

MAS 200

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