Quality Assurance Operations Manager

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SUZETTE HALLMAN

Gasport, NY, *****

*******.*******@*****.*** / 716-***-****

SUMMARY

Seasoned professional in general and operations management with comprehensive experience leading teams, optimizing processes, and implementing cost-effective strategies. Skilled in strategic planning, staff development, and operational efficiency, consistently improving workflow, and reducing costs. Proven track record of enhancing overall business performance through effective leadership and innovative problem-solving. SKILLS

• Performance management

• Data analysis

• Cross-functional collaboration

• Process improvement

• KPI development

• Operations management

EXPERIENCE

Claims Operations Manager / Centivo Corporation - Buffalo, NY 08/2022 - Current

• Key leader instrumental in the development, oversight, and expansion of the claims, quality assurance, member appeals, NSA, subrogation, and training teams.

• Successfully manage the day-today operations of the Claims Department, including: resolving escalated issues; team adherence to policies and procedures; ensuring teams meet/exceed set standards; analyzing, tracking, and trending provider, system setup, and claims errors; reviewing high dollar claims for completeness, accuracy, and approving/denying payment using established guidelines, including all required internal notifications; working with the Configuration Team to ensure proper benefit setup and enhance Auto Adjudication rates.

• Manage staff by creating performance objectives and key metric targets, including scoring rubrics, for all roles in Claims Operations.

• Create and maintain consistent delivery and reporting structure for quality data, including client-specific results, trending, and remediation planning.

• Write, review, revise, and implement standard operating policies, including creation of the department Wiki-based centralized repository.

• Lead cross-functional processes focused on building partnerships with all departments supporting the organization by creating shared goals, strategies and outcomes that lead to improvement of end-to-end customer and member satisfaction.

Manager of Provider Data / UnitedHealthcare - Minnetonka, MN 03/2019 - 08/2022

• Established and maintained the HCBS credentialing process across multiple products (C&S and VA CCN).

• Centralize existing Health Plans to the National Credentialing Center, implemented process improvements, resulting in an increase in operational efficiency.

• Ensured compliance and regulatory requirements were met related to credentialing, contracting, and verification processes.

• Ensured compliance with industry regulations and company policies.

• Established and monitored KPIs to evaluate performance and identify areas for improvement.

• Implemented quality control measures to uphold company standards.

• Managed annual budgeting and forecasting, optimizing resource allocation.

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HCBS Credentialing Supervisor / UnitedHealthcare - Minnetonka, MN 08/2016 - 03/2019

• Developed the department responsible for credentialing Home and Community Based Services Providers for Greenfield Medicaid markets and existing Health Plans centralized to the NCC HCBS Credentialing Team.

• Established and maintained the HCBS credentialing process, including policies, standard operation procedures, reporting, creation of job aids, provider correspondences, scorecards, and quality monitoring program.

• Hired and trained key staff to assist in implementation of the department, including monitoring and managing performance expectations and metrics for credentialing representatives and team. Claims Supervisor - National Accounts / UnitedHealthcare - Minnetonka, MN 03/2014 - 08/2016

• Managed daily inventory needs, including coordinating, supervising, and accountabilities for daily activities of the processors and team.

• Monitored and managed performance metrics for team and individual processors.

• Identified and resolved claims processing issues, errors, and trends. Operations Supervisor, Quality & Training / Nova Healthcare Administrators - Williamsville, NY 02/2012 - 03/2014

• Created and maintained the Customer Service quality monitoring program for two different system platforms.

• Tracked and monitored the performance, quality and satisfaction for Claims and Customer Service Departments, and identified trends in quality results and created additional training programs as needed.

• Created client-specific reporting, analyzed data, and identified trends in quality assurance related issues.

• Reviewed, revised, and implemented standard operating policies.

• Designed, developed, and delivered training, educational programs. Administrative Assistant / Niagara County Health Department - Lockport, NY 07/2011 - 02/2012

• Provided direct supervision to assigned clerical staff and supervision over all other division staff in absence of the Director.

• Assisted the Director and Clinical Supervisor with compiling and preparing statistical data relative to division programs.

• Coordinated personnel function within the division, including interviewing, reference checks, assignment and review of work, work instruction, training, evaluation of work performance, maintaining of work standards, discipline, and morale.

• Performed monthly audit reviews of division records to ensure compliance with standards and regulations.

• Secured and maintained all documentation required for submission of claims to various payers.

• Formulated and maintained division policies and procedures. Senior Insurance Program Assistant / Niagara County Office of Risk Management - Lockport, NY 11/2010 - 07/2011

• Assisted in the oversight of healthcare programs for active and retired employees including interpreting healthcare contracts for employees, retirees and personnel department when inquiring about coverage and coverage issues.

• Supervised and trained Insurance Program Assistant and Clerk positions regarding proper office procedures related to healthcare, disability, property and casualty, and workers' compensation lines of business.

• Collaborated with the Director in the implementation and enforcement of the Niagara County Workplace Violence Prevention Plan, including facilitating the training of all employees, ensuring that the County was compliant with state law.

• Conducted new hire orientation related to healthcare, disability insurance and workers' compensation for all Niagara County Departments.

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Long Term Care Coordinator / Niagara County Office for the Aging - Lockport, NY 07/2007 - 11/2010

• Responsible for the inception of a new grant program which included: Establishing the NY Connects Niagara County program, an information and assistance delivery system for long term care services, specifically targeting the aging and disabled populations of Niagara County.

• Enlisting the participation of long term care service providers, governmental and civic agencies, and community representatives with the county to establish the Long Term Care Advisory Council.

• Developing a public education campaign aimed at increasing public awareness of the program.

• Implementing a comprehensive county-wide resource listing of all long term care service providers.

• Creating and implementing policies and procedures to ensure quality administration of NY Connects Niagara County.

• Hiring, training, and supervising key staff to assist in the implementation of the program.

• Developing a strategic plan aimed at targeting inefficiencies in the long term care system and creating goals and strategies to address identified issues.

• Creating a template public education outreach log adopted by the state for use in all NY Connects programs statewide.

Insurance Program Assistant / Niagara County Office of Risk Management - Lockport, NY 01/2005 - 07/2007

• Oversaw retiree system, including payment tracking, reporting data, financial reimbursements, and budget preparation.

• Processed enrollments for all active and retired employees.

• Assisted in the implementation of healthcare plans, including Summary Plan Descriptions and data preparation.

• Conducted new hire orientation related to healthcare, disability insurance and workers' compensation for all Niagara County Departments.

• Created and maintained reports on retiree population, including payments, Medicare information and accounting records.

• Conducted seminars regarding retiree healthcare and Medicare Part D options.

• Administered 3 fully insured, 1 point-of-service and 5 self-funded healthcare plans for 1,600 active employees and 700 county retirees, including answering benefits questions, processing applications, and resolving customer questions and complaints.

Insurance Program Clerk / Niagara County Office of Risk Management - Lockport, NY 12/2003 - 01/2005

• Tracked monthly payments for employees and retirees.

• Processed enrollments for all retired employees.

• Input workers' compensation and property and casualty claims into claims management system.

• Processed financial reimbursements for county retirees.

• Created and maintained department procedure manual. EDUCATION AND TRAINING

B.S.: Elementary Education 12/2000

State University College at Buffalo - Buffalo, New York A.A.S.: Criminal Justice 12/1993

Niagara County Community College - Sanborn, New York A.A.S.: Banking and Financial Services 05/1991

Alfred State College - Alfred, New York

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