Project Manager Management

KIMBERLY RUX

**** * ***** ****** * MILWAUKEE, WI 53225 * 414-***-**** * **********@*********.***

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CORE STRENGTHS

Planning & Development Operations Management Project Management

Creative Problem Solving Quality Assurance Regulatory Compliance

Leadership/Team Building Vendor Management Quality Control Leadership Contract Management Data Collection Analysts Operational/Financial Audit

Cost Reduction and Profit Growth Processing Mapping Health & Welfare Benefits

Productivity/Performance Improvement

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PROFESSIONAL OVERVIEW

ACS (A Xerox Company)

Senior Business Analyst 2010-2012

• Created and delivers monthly reports to various clients and senior management.

• Served as subject-matter expert on Care & Quality Solutions (CQS) for Health & Welfare benefit plans; owns sole management of all project components of the enrollment process for 24 clients with up to 200,000 participants.

• Reviewed Summary Plan Descriptions (SPDs) from clients and verifies the description against the client’s benefits for accuracy and provides the health plan evaluator with any necessary revisions.

• Functioned as a liaison between the client and client service manager and provides data entry, data system testing, and quality auditing to ensure successful setup for benefits annual open enrollment periods.

• Worked with offshore and outsourcing teams to implement and test health and welfare benefits plans; ensures ongoing process/system capability associated with open enrollment and manages change requests as needed.

• Developed training material for evaluator software; writing, editing, and proofreading.

• Provided training of the Health Plan Evaluator to various clients.

APS HEALTHCARE

Credentialing Manager 2008-2010

• Managed staff, handled interviewing, hiring, employee development, planning, workflow, scheduling, coaching, performance evaluations, salary adjustments, resolution of employee concerns, disciplinary counseling, terminations, and employee morale.

• Analyzed workflow processes; resulting in increased operational performance by 15% while reducing staff by 1 FTE.

• Implemented Auditing programs in Credentialing areas. Increasing quality while maintaining staff levels and improving internal auditing scores.

• Responsible for Provider appeals process; review of complaints and correspondence to providers

• Maintained current knowledge of state and federal and CMS, NCQA, JACHO regulations and ensuring compliance.

• Responded to health plans, clients and/or provider concerns and provided problem resolution as appropriate.

DENTAQUEST (formally Doral Dental)

Director of Claims (2007-2008) 1997-2008

• Managed staff and a department budget; handled interviewing, hiring, employee development, planning, workflow, scheduling, coaching, performance evaluations, salary adjustments, resolution of employee concerns, disciplinary counseling, terminations, and employee morale.

• Optimized productivity 35% through development and implementation of weekly monitoring and reporting methodologies.

• Reduced staff by 3 FTE and processing time from 14 business days to 2 business days by integrating new operating processes.

KIMBERLY RUX

6371 N 118TH STREET * MILWAUKEE, WI 53225 * 414-***-**** * **********@*********.*** * Page 2

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Director of Claims (2007-2008)- continued:

• Reviewed Service Level Agreements (SLA) contracts and fee schedule set ups.

• Maintained current knowledge of state and federal, OIG and CMS regulations and ensuring compliance.

• Established and maintained effective communication and working relationships with clients and providers. Responded to clients, members, and/or provider concerns and provided problem resolution as appropriate.

Project Manager (2002-2007)

• Directed the execution of various cross functional projects from conception through deployment. Provided superior customer care, analyzed processes, created testing methods, coordinated resources, supervised project team, and managed performance.

• Spearheaded and successfully performed the internal Sarbanes Oxley (SOX) audit; identifying operational efficiencies.

• Appointed as a liaison to maintain a positive client working relationship to prevent the organization from losing a multi-million dollar Managed Care client.

• Created and managed new client implementations by developing and preparing test cases and auditing tools to ensure successful set-up systems controls for claims payment.

• Reviewed Business Requirement Documents (BRD) and Healthplan contracts for pre-implementations and made recommendations as appropriate.

• Successfully implemented and/or revised policies, procedures, and processes for various operational areas.

Director, Reimbursement Benefit Auditor & Data Analyst (2002- 2007)

• Managed staff and a department budget; handled interviewing, hiring, employee development, planning, workflow, scheduling, coaching, performance evaluations, salary adjustments, resolution of employee concerns, disciplinary counseling, terminations, and employee morale.

• Designed and successfully implemented company standard policies, procedures, and processes.

• Communicated changes in Medicare and Medicaid reimbursement methodologies and industries trends, providing written updates for senior management.

• Worked with various team members to develop, implement and maintain a high-quality, effective and efficient process for identifying potential reimbursement issues with the Company's pipeline.

• Developed and managed effective client relationship-management strategies which laid the groundwork for securing and retaining client contracts.

• Reviewed various contracts to ensure proper fees schedules were being utilized and to ensure department compliance with each contract requirements.

• Routinely audited random provider payments to review coding procedures, compliance with government, state, and company policies.

• Coordinated, lead, and conduct internal/external financial, compliance and operational audits on various providers and departments of the organization.

• Established and maintained effective communication and working relationships with healthplans, clients and providers.

• Responded to health plans, clients, and/or provider fee and/or contract requirement concerns and provided problem resolution as appropriate.

KIMBERLY RUX

6371 N 118TH STREET * MILWAUKEE, WI 53225 * 414-***-**** * **********@*********.*** * Page 3

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Director of Administration (1999- 2002):

• Managed team members across claims, credentialing, office services and document management and a department budget; handled interviewing, hiring, employee development, planning, workflow, coaching, scheduling, performance evaluations, salary adjustments, resolution of employee concerns, disciplinary counseling, terminations, and employee morale.

• Fostered development of business rules, training materials and integration process for claims and credentialing systems.

• Audited internal operating procedures for compliance with state, federal, CMS, NCQA, JACHO regulations and standard management practices.

• Streamlined credentialing operations by standardizing all processes, systems and procedures; results: credentialing applications processed with 48 hours of receipt and annual auditing scores 98%.

• Performed external hospital audits, presented findings documenting non-compliance with applicable rules and requirements.

• Provided recommendations and corrective action plans to respective clients.

• Implemented Auditing programs for both Claims Processing and Credentialing areas. Increasing quality while maintaining staff levels and improving internal auditing scores.

• Provided constructive recommendations to management and external clients as determined by audit findings.

• Reviewed provider contracts for compliance.

• Responded to clients and/or provider concerns and provided problem resolution as appropriate.

• Responsible for Provider Appeals process; reviewing, discussing and responding to the appeal.

Manager of Claims, Document Management, and Office Services (1998- 1999)

• Managed claims, document management, and office services and a department budget; handled interviewing handled interviewing, hiring, employee development, planning, workflow, coaching, scheduling, performance evaluations, salary adjustments, resolution of employee concerns, disciplinary counseling, terminations, and employee morale.

• Worked closely with external clients on the preparation and responses/corrective actions to operational audits.

• Instituted core operational strategies that increase performance by 25% while reducing labor costs by $125 K.

• Standardized all processes, systems, and procedures, resulting in 99% financial and claim accuracy.

• Collaborated with IT to automate 30% of regulatory reporting process; results: reduced hours from 30 hours to 21 hours and improved accuracy while assuring regulatory compliance.

• Conceived, implemented, and maintained policies and procedures for consolidated departments and internal and external audits.

EDUCATION

MS, Organizational Leadership & Quality & BS, Business Administration- Marian University AA, Paralegal- Milwaukee Area Technical College

TECHNICAL SKILLS

MS Office, Access, SQL, XML Marker, SharePoint, Windows, Work Groups Adobe Acrobat, Visio, and Project

PROFESSIONAL DEVELOPMENT

NCQA certification courses, Six Sigma, and Process Mapping

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