Jacqueline C. Parham

**** ******* *********, ** ***** 313-***-**** adt4mv@r.postjobfree.com

Objective: Healthcare professional with more than 20 plus years of experience, while seeking opportunities for professional growth and continuous improvement

Areas of Expertise:

Customer Service Management

Self-Starter

Insurance/Healthcare Background Skills

Organizational Skills

Subject Matter Expert

Team Building Skills

Client Relations

Appeals & Grievance

Root Cause Analysis

Claim Management

Strategic/Analytical Thinker

Coaching & Development

Facets, PEGA CRM, SharePoint, Care Radius & Power BI

Commercial, Medicare & Medicaid Plans & Centers for Medicare (CMS)

Vendor Management Network

Internal Skills

Professional Experience

Lead - Appeals & Grievance Present

Health Alliance Plan, Detroit MI

Knowledge of the Medicare Advantage, Medicare benefits, Medicaid, Federal Government and all Commercial including Self-Funded benefit guides, contract and riders, eligibility, and direct pay program rates.

Act as departmental subject matter expert (SME) in order to provide guidance, direction and assistance to the A&G department. Research and answer unknown benefit or procedural questions.

Serve as first line contact for A&G Analyst for day-to-day operational issues

Assist department leadership with external vendor management projects within A&G.

Develop and facilitate department meetings, huddle, and member hearings.

Assist with the ongoing for grievances and appeals by working with internal support departments and in accordance with regulatory guidelines.

Lead project initiatives that enhance daily operations, process improvement.

Assist staff with case investigations and back-up support as needed for CTM Complaints, Centers for Medicare and Medicaid Services (CMS) HPMS Portal.

Assist staff with completing case submission to the Maximus QIC Portal & C2C Portal for Medicare Appeals

Support with assisting with Monitoring and Oversight cases reviews by reviewing all grievances and appeals cases before staff mails decision letters to members.

Provide training support to A&G team while identifying procedural gaps in DLPs that need development.

Conduct on-boarding for new and temporary team members.

Lead Customer Service Representative II – (Interim) 9/27/18 to 9/27/19

Health Alliance Plan, Detroit, MI

Primary Job Duties: Provided guidance, direction and assistance to the Client Service Specialist and Coordinated projects with all levels of management

Key Accomplishments:

Provided leadership support to staff and management team. Monitored Client Service Specialist daily by providing guidance, direction, and assistance. Attended meetings, interviews with or on behalf of the supervisor and/or manager.

Assist in workforce management activities including scheduling, time off, queue management

Provided recommendations for improvements as identified

Provided verbal education to members regarding corporate policies and procedures and product philosophies relating to HMO, PPO, AHL and Medicare via telephone, lobby and written

Temporary assignment as a Global Health Care Trainer in a third world country (HGS Jamaica)

Trained new employers and provided ongoing training as necessary

Coordinated, developed, and controlled workflow activities within department. Analyzed phone metrics for forecasting and management of call center operations and collaborated with multiple departments in resolution of member enrollment issues.

Worked Pega management workbasket to complete or assign case work & submit Pega Report to staff for completions. Assist with the maintenance of Desk Level Procedures, departmental policies, and procedures

Created NCQA reporting, FCR reports and statistical reports

Group Services Support Coordinator 4/2009 to 9/2019

Health Alliance Plan, Detroit, MI

Primary Job Duties: Partner with Sales Marketing to drive business results by analyze and providing resolution to group member issues, focusing on trends related to membership, service improvements, claims and create change approach for marketing and customer service

Key Accomplishments:

Provide support to the Sales & Marketing department regarding Large Group; customer site visits to communicate outcomes, presentation with the plan benefits and enhance relations between the groups and producers

Attend meetings to provide updates and present resolutions for key group issues

Manage the litigation process, manage claim recoveries, expedite email request; but not limited to Subrogation, COB inquires and email resolutions for the department and marketing

Identify systemic issues that affect administration of group benefits, coverage, claims processing analyzing and ensuring claims are processed correctly

Serve as liaison between Client Services and other key departments within the organization to provide solutions to systemic issues

Other Positions Held at Health Alliance Plan, Detroit, MI:

Customer Service Supervisor 11/2001 - 09/2009

Lead Customer Service Representative II (AHL/PHP) 11/2000 - 11/2001

Customer Services Specialist I, 10/1997 - 11/1999

Provider Relations Representative I 10/1997 - 11/1998

Behavioral Health Management 04/1993 -10/1997

Education- Memberships

Genuine Leadership Presence – 2018

Participated in Community Giving for HAP - Member 2000

Henry Ford Health System Women in Leadership 2014 – 2018

OAKLAND COMMUMUNITY COLLEGE - 5/2014

Associates of General Studies

Pursing degree for completion of Bachelor’s degree in Health Care Administration with a concentration in Business Management

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