QUALIFICATIONS SUMMARY

An accomplished healthcare professional with 18 plus years of diverse public and proprietary healthcare systems experience with the MMIS conversion to the IndianaAIM system. I have assisted for 6 plus years with managing various aspects of claims processing operations and various personnel. Additionally, I have 15 years of experience working with providers on claim form completion, submission and batch processing of claims including HIPAA X12 transaction and electronic filing. Strong interpersonal and analytical skills. Excellent oral and written communication proficiency. Broad insurance industry experience ranging from various provider relations consultant positions to strong Business Analyst skills and claims processing as well as procedural coding knowledge.

PROFESSIONAL EXPERIENCE

Confidential

Claims Director

• Responsible for managing the day-to-day operations of the Claims Unit. This consists of mailroom, data entry, resolutions, adjustments and professional staff that support the operations of the Indiana Health Coverage Program.
• Ensure that claims are processed according to the IHCP guidelines as it pertains to billing procedures and procedure coding guidelines.
• Prepare and maintain detail reports of claims volumes for all units to include mailroom, data entry, resolution and adjustments.
• Monitor all staff performance to ensure that quality and production standards are maintained.
• Ensure that all staff in the claims unit comply with HIPAA privacy and security standards.
• Serve as a liaison for the Claims Unit and the Indiana Family and Social Services Administration IFSSA .
• Ensure that all contractual obligations are met for the Claims Unit.
• Ensure that compliance with all Claims Unit Operational Procedure Manuals are up to date and compliant.
• Perform all personnel administration for all staff members in the claims unit. This is to include performance reviews, salary and variable bonus administration.
• Ensure that the Reference subsystem is compliant with claims processing for the IHCP.
• Ensure that all issues pertaining to claims processing are addressed and resolved in a timely manner.
• Serve as a Client Tower Lead CTL to the IFSSA for the Medical Review Team MRT and Pre-Admission Screening and Residential Review PASRR programs.
• Responsible for interviewing and hiring personnel for the Claims Unit.

Claims Resolution/Adjustment Supervisor

Confidential

• Responsible for supervising the day-to-day operations of the resolution and adjustment unit and ensure the claims are processed according to IHCP guidelines as it pertains to billing procedures and procedure coding guidelines.
• Prepare and maintain detail reports of claim suspense activity and having responsibility for all examiners and clerks in the resolution unit.
• Monitor staff performance to ensure that quality and production standards are maintained.
• Ensure all staff comply with HIPAA privacy and security standards.
• Serve as a liaison between the Resolutions Unit and other EDS departments and the Indiana Family and Social Services Administration IFSSA .
• Ensure that the Resolutions Unit's and Adjustment Unit's contractual obligations are met.
• Manage the adjustment transaction process.
• Develop and maintains all adjustment and resolutions operating procedure manuals.
• Perform personnel administration.
• Researches and processes special adjustment and claim requests received from other departments.

Business Analyst-Systems

Confidential

• Project Analyst for various changes to the IndianaAIM System. This includes informal leadership to business analysts for the account.
• Assisted with the implementation of the First Steps program.
• Performed claims testing related to the First Steps program to ensure that claims processed appropriately to the program specifications that were defined.
• Assisted the Project Manager with meetings and activities related to First Steps.
• Assisted with all training workshops related to the implementation of the First Steps Program.
• Performed requirements review as a SME for change requests submitted to the Systems department.
• Performed training activities associated to the bi-monthly training that is conducted across the account and for OMPP staff.
• Business Team Lead for the implementation of the First Steps WEB SPOE Project.
• Performed requirements review of all NPI detailed level requirements
• Responsible for gathering requirements for the First Steps program related to the NPI project.
• Assisted the Client Services, Provider Relations team with training new staff and the 2006 Annual Seminar.

Business Support Team Reference Team Lead

Confidential

• Implemented the Reference change request process.
• Served as a primary contact to the OMPP staff with regards to all Reference Change Requests.
• Logged and assigned all Reference requests to the reference team.
• Lead the monthly Reference File meetings held at OMPP.
• Performed Reference updates to the system.
• Performed testing associated to Reference file requests prior to implementing the changes to the systems as it related to claims processing and procedural coding guidelines.
• Account Subject Matter Expert SME for all Crossover and FQHC related issues.
• Assisted with performing updates to the Pricing Manual.

Business Support Team-Reference

Confidential

• Assisted with the implementation of Issue Management. This included training all parties using Issue Management.
• Monitored and assigned Issue Management requests to staff across the account.
• Assisted the Business Support Team Manager with resolving any issues that were associated to the defect of claim processing that involved the provider community.
• Interacted with the OMPP with regards to changes to state policy regarding reference updates.
• Performed claims testing for implementation of change order requests.
• Performed Reference Team daily activities and Annual CPT and HCPCS updates.

Account Services

Confidential

• Assisted as interim supervisor over the Written Correspondence staff which involved monitoring of staff and all written inquires that were mailed to the provider community.
• Performed contract monitoring activities.
• Responsible to help educate and train new individuals joining the provider relations team.
• Assisted with Reference Team daily activities and Annual CPT and HCPCS updates.
• Assisted with HIPAA implementation in performing claims testing
• Assisted in review of provider manual.
• Assisted in claims testing for implementation of change order requests.
• Performed all Systems Engineer SE requests that were sent to the Systems Team for review. Monitoring, reviewing the need for SE involvement, and responding to the request was included in these daily activities.

Provider Relations Field Consultant Team Lead

Confidential

• Implement and execute the Annual Training Plan objectives.
• Team leader of provider workshop presentations and developing training materials.
• Responsible for helping educate and train new individuals joining the provider relations field consultant staff.
• Educate providers by on-site visits, workshops and association meetings.
• Monitor staff members in regards to developing and reviewing all PowerPoint presentations and workbook materials.
• Educate providers on claim form completion, submission and batch processing including HIPAA X12 transaction and electronic filing.

Provider Relations Field Consultant

Confidential

• Responsible for the Central Indiana Marion County geographic region.
• Conduct provider training for all provider types in assigned program areas currently servicing providers utilizing the HCFA 1500 claim form.
• Facilitating outreach activities and educational workshops and performing on-site problem resolution i.e. claim for completion, commercial insurance and Medicare .
• Responsible for educating and assisting providers and all billing staff on all claims policy and system matters associated with the HCFA 1500 provider community.
• Provide education to the Managed Care Program both for Primary Care Case Management PCCM and Risk-Based Managed Care RBMC , and First Steps.
• Support and Market the Electronic Claim Capture software to the provider community.
• Recruit and retain new providers into the Medicaid Program.
• Responsible to lead and conduct provider association meetings for the Indiana State Medical Association ISMA , AIHMES DME Association , and the Indiana Podiatry Association.