Service Delivery Customer

Stanley W. Robinson

Las Vegas, NV ***** 916-***-****

linkedin.com/in/stanley-robinson **************@*****.***

Superior Healthcare and Insurance Leader

Business Analysis Claims Operations Team Training and Management

•Innovative, tactical professional with over 25 years of expertise in healthcare solutions, compensation, payment adjudication, provider reimbursement, and quality assurance review

•Possess a solid knowledge of claims processing and timely filing procedures with claims inventory management, process improvement, critical problem-solving, and researching and developing claims management and resolution system implementations

•Demonstrated success in time management, task prioritization, project organization, and process improvement to increase claims submission and processing quality

•Excel at blending technical and business expertise, using project tracking and visibility tools, leading teams, understanding industry trends, anticipating new and changing demands, presenting to other members of leadership, and developing outstanding internal and external relationships including top management, employees, vendor, and partner relationships

Areas of Expertise:

UAT testing System implementation System configuration group and provider setup Inventory management Process improvement Agile project management System training Auditing Business administration and troubleshooting Team leadership and feedback Operations management Strategic planning Relationship building and management Technology product development and management Control systems Regulatory requirements

Technical Skills:

QicLink QNXT Facet EZ-Cap Amisys BlueCard host ikaSystems Automation tools QTP, PEGA, UltraEdit, and Copy Tool

Experience

OPTUM GLOBAL SOLUTIONS /Equity Staffing, Las Vegas, NV (2020 – 2021)

Associate Director Business Analysis

Oversaw the strategy, direction, innovation, and overall execution of high visibility initiative such as new digital and technology programs, championed technology and innovation as a strategic partner critical to mission and vision fulfillment, and drove increased engagement in line with organizational goals.

•Served as operation subject matter expert (SME) on workflow creation processes and process improvement.

−Provided guidance on implementation and adoption of efficient claim processing.

•Provides analysis and support on topics such as the competitive environment, health care industry, government relations, and new market opportunities.

•Offered fresh and innovative solutions to address difficult and long-standing challenges in improving health care outcomes.

•Supported senior leaders on engagements with and influencing broad public health care policy development.

Integrated Home Care Services, Inc., Miramar, FL (2019 – 2020)

Claims Director

Stanley W. Robinson

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Experience (continued)

Directed the processing and payment of claims, provided guidance on complex claims, developed short and long-term service objectives, and monitored and ensured policy and procedure adherence.

•Implemented optical character recognition (OCR) scanning of paper claims.

−Decreased backlog and turnaround time of the processing of claims by 50% by implementing process improvements and efficiencies.

•Planned, developed, and managed key system configuration enhancements based on contractual requirements.

•Effectively planned staff responsibilities, managed activities, and utilized staff resources to meet department goals in accordance with established business plans and budgets.

•Identified training needs and established and implemented delivery strategies for staff-level employees.

•Ensured contractual compliance of claims adjudication process.

•Improved service level agreement (SLA) for turnaround time (TAT) and claims submission to health plan.

Cognizant Technology Solutions (and acquired company, TriZetto), St. Louis, MO (2014 – 2019)

Team Manager, 2018 – 2019

Functioned as SME on Amisys system, managed 10 UAT system analysts, provided guidance and leadership to UAT team, and ensured timely completion of tasks assigned to all team members.

•Created User Acceptance Testing (UAT) test plan from user stories from Jira provided by Centene Corporation and provided client-facing status updates on test cases.

•Created policies and procedures for UAT for usage at Centene for Cognizant.

•Submitted test plans to product owners and Scrum Master for review and approval.

Claims Manager II, 2015 – 2017

Administered claims processing systems, rules, and policies, managed claim staff comprised of 10 onshore full-time equivalent (FTE) and 25 offshore FTE positions, researched and resolved adjustment inquiries, and provided knowledge and industry expertise to key partners.

•Created and executed claims resolution strategy to ensure SLA measurement aligned with client requirement.

•Reviewed working reports to proactively identify potential issues and participated in business reviews and regularly held meetings in conjunction with service delivery representative or senior service delivery representative.

•Built and promoted strong personal relationships with key associates, supported and provided measurement for the audit process, and implemented policies, procedures, and updates.

•Resolved escalated issues from the clients on claims processing issues and the issues process and created business review documents (BRDs) for each client’s claims processing guidelines for Facet, QNXT, and QicLink applications.

Claims Operation Fulfillment Manager, Business Management System/Business Process Outsourcing (BMS/BPO), 2014 – 2015

Oversaw order fulfillment, quality control, and shipping, maintained vendor contracts in the fulfillment implementation process, and resolved escalated client fulfillment implementation issues.

Stanley W. Robinson

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Experience (continued)

•Created project planner for implementation logs to capture progress of implementation and defect during the process.

•Tracked implementation processes and created BRDs for each client implementation.

•Monitored and audited file output from vendors Emdeon and Laser Mark to ensure processes met client SLA requirements.

•Facilitated business meetings with clients and vendors and managed the entire fulfillment process for the project, from welcome kits to identification cards, invoices, checks, explanation of benefits (EOB), electronic data interchange (EDI), and system information (SI) engagement, to ensure mapping between vendor and time zone (TZ) processes were correct.

•Worked collaboratively with all department heads on the Medicare Enrollment Process Improvement Plan (MEPIP) project to identify fulfillment gaps, streamline procedures, and provide cost savings for TriZetto.

Inetico, Inc., Tampa, FL (2013 – 2014)

Director of Claims Operation

Directed claims operation processing customer claims for coverage, monitored work queues and ensured the smooth transition of EDI claims to the appropriate queues and network, and oversaw client-requested claims audits in accordance with policies and procedures for vendor relations.

•Maintained an 80% success rate of negotiated claims and prenotification agreements and created and improved written workflows, policies, and procedures for claims staff.

•Implemented and set up new groups and assigned appropriate Preferred Provider Organization (PPO) flows.

•Managed all escalated client and vendor customer service calls and emails.

•Assisted IT department in implementing Medicare fee schedules for PAR3 and PR30 for Inetico PPO line of business and troubleshot system issues.

•Facilitated senior management meetings and provided updates to new and existing client implementation process improvements in the adjudication of client submitted claims.

•Directed inventory reduction planning and execution on all work queues to stay within SLA compliance.

Dell Perot Systems/Synergy, Lincoln, NE (2012 – 2013)

Quality Assurance (QA) Tester

As contracted employee, validated benefits on Blue Cross Blue Shield of Michigan’s Medicare Advantage program BPO operation, including system integration testing (SIT) and UAT on claims and eligibility, billing, and provider PPO modules, for new application enhancements and defect management through systematic identification, manual intervention, and regression testing on ikaSystems application.

•Recorded all test scripts and execution on Quick Test Professional (QTP) automation tool and monitored assignment on Microsoft Project.

•Program went live and encompassed 200K members and 80 different plans, 2013.

Beacon Health Solutions, Tampa, FL (2010 – 2011)

Claims Manager

Stanley W. Robinson

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Experience (continued)

Managed Jackson Memorial Hospital Medicaid and Passport Advantage Medicare/Medicaid contracts, hired staff, conducted performance appraisals, and resolved employee conflicts.

•Managed inventory, auditing, duty assignments, time service analysis, and system issues and resolutions.

•Managed a staff of 29 claims specialists, maintained a turnaround time of under 15 days for both contracts, and facilitated client meetings for problem resolution, implementation, and ikaSystems usage training.

•Wrote policies and procedures for Medicare and Medicaid lines of business and ensured staff was fully trained on the business processes of both.

•Provided training on crossover Medicaid/Medicare coordination of benefits (COB) claims for staff to ensure guidelines were being adjudicated correctly by claims staff.

Jacobson Solutions, Chicago, IL (2008 – 2009)

Claims Consultant – Project Lead Manager

As contracted employee, supervised an auditing team performing system configurations on QicLink, a TriZetto platform for UnitedHealthcare PPO provider database, directed staff in project assignments, and provided analytical expertise in interpreting contracts and reprocessing claims.

•Exceeded production and quality standards set by senior management.

•Guided personnel in assigned projects and inventory tracking, communicated individual improvements, and identified additional departmental needs.

•Facilitated meetings with staff and UnitedHealth Group’s senior management team on the progress of PPO contract updates and created project planner to monitor and track project development.

•Processed Medicare claims on Blue Card Host System for Blue Cross Blue Shield of Texas.

Kaiser Permanente, Oakland, CA (2002 – 2007)

Quality Assurance Coordinator

Performed internal audits to ensure operational policies and procedures were administered according to health plan (HP) benefits for members and groups and quality assurance standards were met.

•Reviewed procedural audit reports of adjudicated claims in compliance with compensation and quality guidelines and utilized audit findings to retrain staff on claims operations.

•Provided feedback on accuracy and productivity levels and recommended appropriate counseling and training to improve employee work performance.

•Prepared qualitative goal reports for regulatory agencies and group requirements and mandates.

•Assisted with resolving issues regarding policy interpretation and contract administration for Medicare Senior Advantage Plan.

Professional Development

Coursework taken in Health/Health Care Administration/Management, Colorado Christian University, Lakewood, CO

A.S., Business Administration, Sacramento City College, Sacramento, CA

Kappa Alpha Psi Fraternity member

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