J E E VANS H AY B L A K E - BR OWN 404-***-****

** ***** **** *********, ** 30014 adwr09@r.postjobfree.com

Objective

Energetic healthcare professional with customer service, administrative and management experience. A skilled leader and team member, able to maintain a positive attitude and productive work environment. Proficient in managing and supervising new employees. Hardworking, reliable, and dedicated. Talented in prioritizing and completing tasks promptly, yet flexible to multitask when necessary. Comfortable interacting with all levels of personnel and the public. Excellent problem solving and time-management skills. Take pleasure in learning new programs. Ability to work in a fast-paced environment.

Professional Experience

Pathways Behavioral Consulting Quality Assurance

McDonough, GA February 2020 – Current

Quality Assurance

Daily, weekly, and monthly audits of client files and clinician SOAP notes

Monitor and maintenance of various spreadsheets for tracking of accreditation and insurance requirements for staff files and client files.

Monthly Medicaid insurance eligibility completed for all active clients.

Annual VOB’s completed for clients with commercial insurance.

Credentialing Coordinator

Enrollment of all new providers. Completed online applications, establishes provider login and credentials for record.

Enrolled providers in Medicaid, Medicaid CMO’s and private insurance panels (BCBS, Cigna, Aetna, UHC, Tricare, Beacon, Magellan, etc.)

Maintained CAQH profiles for attestation, expired license and/or certifications and necessary uploads for the BCBA and BCaBA

Utilizations

Review of completed assessments and the supporting documentation, providing feedback of any corrections needed prior to submission of authorization request.

Submission of ongoing assessment authorizations, initial and ongoing treatment authorizations, attaching the required documents for proof of medical necessity

Tracking of authorizations from beginning to end, uploaded and additional documents requested to receive an approval

Submission of change request (i.e., change in rendering provider, location, etc.)

Entry of authorizations approval in the EMR

Systems Utilized: Kareo, NPA, Trello, Catalyst, CAQH, NPPES, Availity, GAMMIS, PECOS, Paycor

Elemy Credentialing Specialist

Miami, FL (Remote, Contract) June 2022 – February 2023

Responsible for completion of initial and reappointment applications for physicians, assuring compliance with regulatory and accreditation standards, as well as the state Health Bylaws, Policies and Procedures, Rules & Regulations for FL, TX and CA.

Coordinates the timely processing of all activities of initial and reappointment applications for completeness and in accordance with appropriate standards relative to the organizations Credentialing Manual. Provides credentialing support to the credentialing manager and supervisor. Communicates with Medical Staff Liaisons during the credentialing process.

Preparation and accuracy of credentialing reports at least one week prior to dues date for submission to Management.

Research incidents, submission of applications for timely processing, and request appropriate follow-up information as needed. o May be responsible to gather information and perform research in credentialing disputes under the direction of the Management. o Protects confidential information for peer review by the authorized personnel.

Secures appropriate peer competency references and prepares credentials files. Obtains primary source and other verifications in accordance with established guidelines. Communicates with applicants during credentialing process to ensure timely and expeditious completion of process. Research incidents, malpractice claims, advisory letters/letters of concern etc. and request appropriate follow-up information from practitioner or other sources as indicated.

Initiates and participates in cross-training and cross-coverage of credentialing departmental functions. Serves as departmental resource to employees. Mentors and assists other Credentialing Specialists in all aspects of credentialing functions and training.

Maintains the credentialing database. Ensures data is accurately entered as evidenced by audit. Prepares reports in compliance with requests for information as demonstrated by documentation.

Participates in departmental PI initiatives, including regulatory preparedness.

Coordinates and completes special projects in a timely manner. Appropriately prioritizes all tasks so that deadlines are met with continued focus on quality. Keeps staff apprised of any critical or major situations.

Drafts and assists in writing and reviewing policies and procedures and department rules and regulations. Ensures these do not conflict with medical staff by-laws and hospital policies and procedures/protocols.

Interacts daily with medical staff leadership, department chairs, administration medical staff services team and executive staff.

Provides exceptional customer service to all internal and external customers, including physicians, advanced practice professionals their office staff, other departments, and within the Medical Staff Services team.

Maintains reasonably regular, punctual attendance consistent with state Health policies, the ADA, FMLA and other federal, state, and local standards.

Systems Utilized: Kareo, NPA, Trello, Catalyst, CAQH, NPPES, Availity, PECOS, Salesforce, Verify Stream, ADP, Rippling

Comprehensive Counseling Solutions, Inc. Utilization Management/Quality Assurance Manager

Atlanta, GA October 2018 – January 2020

Efficiently and accurately communicate coverage decisions to clients, providers, and medical staff, following timelines established by regulations and standards of operation.

Responsible for interfacing with other departments in the matter of review decisions, discharge planning, and fiscal communication

Providing general oversight of the department

Collecting, tracking, and reporting metrics for the department

Producing consistent, sound, and defensible coverage decisions, according to established written agency policies, level of care guidelines and departmental protocols.

Obtaining initial (pre-certification), concurrent and retrospective authorization for programs: CORE, IOP, PHP per fund source allowances as determined by medical necessity. Retrieval of reports for expired and exhausted authorizations to support submission of the request to appropriate fund source for initial and concurrent treatment.

Set alerts as needed to safeguard against misuse of authorizations.

Assigning assessments and review of completed assessments (i.e., BHA, Diagnostic, Substance, etc.) of qualified practitioners.

Technical review and locking of clinical assessments, medical team assessments, and BIRP Note

Responsible for referrals, conducting clinical reviews of proposed services against appropriate criteria/guidelines to determine medical necessity, level of care and eligibility.

Collaborating with physicians and/or qualified practitioners to secure signatures of service orders.

Weekly audits of client files and updating of information in appropriate technology systems. Notification of deficiencies communicated to specific area/departments.

Filing, scanning, and uploading of submitted documents for client file and processing of medical record request.

Administrative discharge of clients, as needed.

Participation of weekly management meetings with leadership

Systems Utilized: Kareo, NPA, Trello, Catalyst, CAQH, NPPES, Availity, PECOS, Sharenote, ADP

ASFC Outreach Therapeutic Counseling Services, LLC Utilization Management/Office Manager/Billing Covington, GA February 2017 – September 2018

Participate in weekly meetings with the Clinical Director

Participate in Treatment Team meetings.

Maintain professional relationships with all department personnel, county personnel, consumers, families, and service providers.

Complete Medicaid registrations and reauthorization through Provider Connect for CORE initial and ongoing services Tier 2 and Tier 2+ services,

Complete and submit CMO authorization requests for services that require prior authorization based on medical necessity.

Participate in professional development opportunities as deemed appropriate or necessary with Clinical Director and/or CEO approval.

Bi-monthly and/or monthly monitoring of units utilized by clinical staff.

Prepare Non-Medical and MD Orders for the signature of authorized staff.

Monthly audits of client files to ensure that the required documents along with signatures are present in the client’s paper chart and/or electronic file

Tracking of bi-annual and annual assessments and expirations (i.e., BHA, tx plans, CANS/ANSA, diagnostics, nursing assessments, safety plans, etc.)

Assist with company audits from various fund sources (i.e., Medicaid, Amerigroup, Cenpatico, WellCare)

Related responsibilities center around weekly monitoring of the number of units utilized vs. what was authorized and notification to the individuals who implement the necessary services (i.e., authorization request and treatment plan complete with the clients) to prevent a lapse in authorizations and/or exceeding utilization of units during a current authorization.

Tracking of initial and discharge CANS/ANSA scores and maintain flow chart for scores needed for PMR tracking.

Enter authorizations and treatment plans into the EMR.

Provide requested reports quarterly needed for completion of the annual PMR reports.

Assist with credentialing of staff with private insurance panels.

Random Q&A calls conducted to ensure the clients are receiving and the staff is rendering quality care.

Tracking of service delivery to ensure the staff are providing the frequency of services documented.

Managing staff schedules to provide proper coverage for the office.

Keeping an inventory of office supplies and ordering when supplies are needed

Maintenance of office equipment and/or contacting vendors necessary to repair.

Billing:

Submission of an electronic claim through the online portal for Medicaid, Medicare, Amerigroup, Cenpatico, WellCare, CareSource and BCBS

Reconciliation of claims due to insurance denials

Submission of 1500 claims for private insurance Aetna, Humana, United Healthcare, Cigna

The Potter’s House Family & Children Treatment Center Program Manager/HR Administrator

Stone Mountain, GA October 2015 – January 2017

Managed and overseen the operation of the Front Desk, Utilizations, Medical Records, TAP and Clinical staff.

Applies professional level of knowledge of federal and state assistance programs and accrediting bodies for a child, adolescent, and adult populations.

Participate in weekly Program Meeting with leadership.

Maintain a schedule of weekly Treatment Team meetings and oversee/supervise such actions within the program.

Maintain professional relationships with all agency personnel, personnel of governing bodies/regulatory agencies, consumers/clients, families, and/or other service organizations/agents.

Perform staff evaluations and training plans as appropriate.

Ensure that admissions practices and utilization management practices are consistent with regulatory guidelines as well as professional standards of practice.

Monitor and ensure compliance as per regulatory guidelines.

Monitor patient outcomes and complete required written reports.

Participate in professional development/continuing education and maintain licensure.

Conducted interviews, extended job offers and conducted orientation for new hires.

Reconciliation of insurance denials

Communicated and worked closely with CEO and COO to ensure day to day operations were being managed.

ASFC Outreach Therapeutic Counseling Services, LLC Utilization Management Coordinator/Compliance Covington, GA April 2015 – September 2015

Participate in weekly meetings with the Clinical Director

Participate in Treatment Team meetings.

Maintain professional relationships with all department personnel, county personnel, consumers, families, and service providers.

Complete MICPs or OTRs as needed for CORE initial and ongoing services.

Participate in professional development opportunities as deemed appropriate or necessary with Clinical Director and/or CEO approval.

Bi-monthly and/or monthly monitoring of units utilized by clinical staff.

MD Orders

Maintaining client audit sheet

Related responsibilities center around weekly monitoring of the number of units utilized vs. what was authorized and notification to the individuals who implement the necessary services (i.e., OTRs and treatment plan complete with the clients) to prevent a lapse in authorizations and/or exceeding utilization of units during a current authorization.

Monitor CAFAS scores and maintain flow chart for CAFAS scores of consumers.

Enter authorizations and treatment plans into the EMR.

Compliance

Bimonthly and/or monthly auditing of client charts to ensure the required documents per DBHDD and CARF guidelines are completed.

Review and/or monitoring of applications needed for updating credentials for existing and new ASFC locations. Applying and submitting the required documents.

Working closely or in conjunction with the Intake Assessment Manager

Completing tracking reports required by CARF and DBHDD and/or building necessary spreadsheets to ensure the required tracking reports are in place.

ASFC Outreach Therapeutic Counseling Services, LLC Operations Coordinator/Compliance

Covington, GA October 2014 – April 2015

Improve the operational systems, processes, and policies in support of organizations mission -- specifically, support better management reporting, information flow and management, business process and organizational planning.

Manage and increase the effectiveness and efficiency of Support Services (HR, IT and Finance), through improvements to each function as well as coordination and communication between support and business functions.

Play a significant role in long-term planning, including an initiative geared toward operational excellence.

Oversee overall financial management, planning, systems, and controls.

Management of agency budget in coordination with the Executive Director.

Development of individual program budgets

Invoicing to funding sources, including calculation of completed units of service.

Payroll management, including tabulation of accrued employee benefits.

Disbursement of checks for agency expenses.

Organization of fiscal documents.

Regular meetings with Executive Director around fiscal planning.

Supervise and coach office manager weekly.

Electronic billing and research for denials and remittance of claims for Medicaid, WellCare, Amerigroup, and Cenpatico

Compliance:

Develops initiates, maintains, and revises policies and procedures for the general operation of the Compliance Program and its related activities to Analyzes/Develops/Recommends/Coordinates complex systems and practices for modifications and enhancements to allow the implementation of changes to ensure that program goals are met.

Completes required federal governmental reports to ensure that data collection and reporting procedures meet mandated regulations of CARF and Medicaid, etc...

Develops and periodically reviews and updates Standards of Conduct to ensure continuing currency and relevance in guiding management and employees.

Collaborates with other departments (e.g., Risk Management, Internal Audit, Employee Services, etc.) to direct compliance issues to appropriate existing channels for investigation and resolution. Consults with the corporate attorney as needed to resolve difficult legal compliance issues.

Responds to alleged violations of rules, regulations, policies, procedures, and Standards of Conduct by evaluating or recommending the initiation of investigative procedures. Develops and oversees a system for uniform handling of such violations.

Acts as an independent review and evaluation body to ensure that compliance Issues/concerns within the organization are being appropriately evaluated, investigated and resolved.

Monitors, and as necessary, coordinates compliance activities of other departments to remain abreast of the status of all compliance activities and to identify trends.

Identifies potential areas of compliance vulnerability and risk; develops/implements corrective action plans for resolution of problematic issues and provides general guidance on how to avoid or deal with similar situations in the future.

Provides reports regularly, and as directed or requested, to keep the Chief Executive Officer and senior management informed of the operation and progress of compliance efforts.

Ensures verified diagnosis, the order of services, triage documentation complies and proper reporting of violations or potential violations to duly authorized enforcement agencies as appropriate and/or required.

Institutes and maintains an effective compliance communication program for the organization, including promoting (a) use of the Compliance; (b) heightened awareness of Standards of Conduct, and (c) understanding of new and existing compliance issues and related policies and procedures.

Works with the Human Resources Department and others as appropriate to develop an effective compliance training program, including appropriate introductory training for new employees as well as ongoing training for all employees and managers.

Monitors the performance of the Compliance Program and relates activities continuously, taking appropriate steps to improve its effectiveness.

Assures all agency compliance by completing random quality assurance audits, provides verified diagnosis and coordinates with MD to assure such delivery. Assures agency billing compliance. Coordinates surveys, questions, and referrals for coordinating program activities with the program administrator, area agencies, local districts, program staff, and parents.

Participates in staff meetings and training, collaborating with staff, other departments, divisions, and outside agencies for assisting others to understand the program policies and procedures, responding to requests for information and ensuring that the behavioral health services requirements are understood, and procedures followed.

Participates in weekly internal consumer chart audits to ensure compliance with services rendered, billing codes used and that all required Medical and Non-Medical orders were completed and filed in a timely fashion.

ASFC Outreach Therapeutic Counseling Services, LLC Human Resources Manager/Office Manager Covington, GA July 2014 – October 2014

Maintain knowledge of and ensure compliance with employment-related laws and regulations.

Manage actions and proceedings brought against ASFC arising in connection with employment, benefits and workers compensation issues, including preparation of responses to EEOC charges and management of outside counsel.

Maintain all personnel files, I-9 records, drug and alcohol screening, and background investigation results, and other personnel records, and ensure ASFC follows all laws and regulations and demonstrates “best practices” regarding personnel information management.

Provide leadership in effective conflict resolution for all personnel.

Analyze benefits options and cost alternatives for providing employee benefits, recommend benefits program modifications and implement approved benefits modifications.

Work with senior management to craft consistent, equitable and competitive compensation and incentives.

Develop and implement human resources programs and policies and periodically update ASFC’s Team Member and Team Leader Handbooks.

Serve as a resource for team leaders in handling employee issues and assist them in counseling employees, conducting evaluations, staff training, problem-solving and consensus-building.

Serve as a resource for all team members by being available and accessible to discuss all human resources related issues.

Maintain inter- and intradepartmental workflow by providing information to and cooperating with co-workers.

Assist in hiring by providing job descriptions and advertisements, and in the ASFC case of hiring of senior team leaders, by screening and interviewing ASFC candidates.

Work with the CEO on matters involving benefits, employee safety, and worker's compensation issues.

Oversee handling of employment-related inquiries, such as employment verification requests and unemployment compensation inquiries and proceedings.

Develop, implement, and participate in employee recognition programs.

Enhance job performance by applying up-to-date professional and technical knowledge gained by attending seminars and conferences and reviewing professional publications.

Perform other duties as assigned by CEO, Compliance Officer, or other senior management.

Assist with Medicaid, WellCare, Cenpatico, Amerigroup electronic billing and preparation of 1500 forms for private pay claims.

ASFC Outreach Therapeutic Counseling Services, LLC Operations Support

Covington, GA June 2013 – July 2014

Ensure consumer information is accurate including billing information.

Maintain and manage consumer records (paper & electronic-Sharenote).

Ensures knowledge of staff movements in and out of the facility.

General administrative and clerical support tasks.

Prepare compliance letters and documents.

Check and update the BHL calendar for referrals.

Verified eligibility and authorization Medicaid, Cenpatico and all other CMOs.

Assume receptionist duties, as needed, greet public and refer them to appropriate staff members, answer the phone, route calls, and take messages.

Assist with the completion of necessary statistical reports as requested.

Compile statistical information for Compliance Officer/ Clinical Director as requested.

Maintain appropriate interpersonal relationships with employees, peers, and consumers.

Assist with various program operations as requested as responsibilities permit.

Assist the Utilization department with necessary documents for consumers.

Process work orders from staff members.

Prepare paperwork and operations for clinic days.

Maintain vault schedule and access.

Audit and prepare consumer files.

Receive and screen new referrals and schedule the intakes.

Completion of initial and ongoing MICPS

The input of Treatment plans and authorizations into the electronic filing system.

Prepared Medical and Non-Medical Orders for initial and ongoing consumers.

ASFC Outreach Therapeutic Counseling Services, LLC Executive Assistant for the CEO

Covington, GA June 2012 – June 2013

Completed a broad variety of administrative tasks for the CEO including managing an extremely active calendar of appointments; completing expense reports; composing and preparing correspondence that is sometimes confidential; arranging complex and detailed travel plans, itineraries, and agendas; and compiling documents for travel-related meetings.

Planned, coordinated, and ensured the CEO's schedule is followed and respected.

Communicated directly, and on behalf of the CEO, with Board members, donors, Foundation staff, and others, on matters related to CEO's programmatic initiatives.

Researched, prioritized, and followed up on incoming issues and concerns addressed to the President, including those of a sensitive or confidential nature. Determined appropriate course of action, referral, or response.

Provides a bridge for smooth communication between the CEO and internal departments; demonstrating leadership to maintain credibility, trust, and support with senior management staff.

Worked closely and effectively with the CEO to keep her well informed of upcoming commitments and responsibilities, following up appropriately. Provided leadership to build relationships crucial to the success of the organization, and manages a variety of special projects, some of which may have organizational impact.

Completed critical aspects of deliverables with a firsthand approach, including drafting acknowledgment letters, personal correspondence, and other tasks that facilitate the CEO's ability to effectively lead the company.

Prioritized conflicting needs; manages matter expeditiously, proactively, and follows-through on projects to successful completion, often with deadline pressures.

ASFC Outreach Therapeutic Counseling Services, LLC Administrative Assistant

Covington, GA February 2011 – June 2012

Assumed receptionist duties, as needed, greet public and refer them to appropriate staff members, answer the phone, route calls, and take messages.

Assisted staff with administrative duties as requested.

Cooperate in the maintenance and/or modification of the agency data collection system.

Oversee database management for quality assurance.

Provide training to staff.

Assist with the completion of necessary statistical reports as requested.

Compile statistical information for Compliance Officer/ Clinical Director as requested.

Update and maintain mailing lists.

Produce mailing labels and reports as requested.

Maintain appropriate interpersonal relationships with employees, peers, and consumers.

Assist with various program operations as requested as responsibilities permit.

Other duties as assigned.

Certifications

CPR/AED

CPI

References

Upon request

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