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Supervisor Of Ppo/hmo Resume

SUMMARY

  • 15 years claims experience with Group health and workers’ compensation claims.
  • Audited providers on claims data including Medical, Dental and pharmacy claims.
  • Excellent reporting and presentation skills
  • Manage and supervise all staff and coordinate all activities related to billing and collection of all types of HMO/CAP, PPO, and Confidential ’s Comp. claims.
  • Responsible for training staff on billing and collection rules and regulations, related policies and procedures in place by the department, and provide clarification on contract interpretation.

OBJECTIVE

  • Seeking to enhance my healthcare experiences and utilize my extensive knowledge of workers’ compensation and healthcare billing practices with a company that would value these assets.

TECHNICAL SKILLS

  • Business requirements
  • Business analysis
  • Project briefs. RFPs. ROI analysis
  • Testing
  • Project Management
  • Medical billing including Medicare
  • Medicaid
  • HMO
  • Medical terminology
  • ICD - 9
  • CPT
  • HCPCS coding
  • System Analysis
  • Testing Methodologies
  • System development lifecycle
  • Word processing
  • Data Entry
  • Telephone etiquette
  • customer service
  • MS Word
  • Access
  • Excel
  • MS Project
  • Outlook 

PROFESSIONAL EXPERIENCE

Confidential

Supervisor of PPO/HMO

Responsibilities:

  • Manage and supervise all staff and coordinate all activities related to billing and collection of all types of HMO/CAP, PPO, and Confidential ’s Comp. claims.
  • Responsible for training staff on billing and collection rules and regulations, related policies and procedures in place by the department, and provide clarification on contract interpretation.
  • Ensure monitor and address external vendor performance, personnel issues.
  • Coordinate any necessary communication to and from the payers.

Confidential

Operations Manager

Responsibilities:

  • Plan, organize, direct, and coordinate the workers and resources of the restaurant for the efficient, well-prepared, and profitable service of food and beverages.
  • Work with other management personnel to plan marketing, advertising, and any special restaurant functions
  • Comply with all health and safety regulations

Confidential

Review Manager

Responsibilities:

  • Responsible for meeting the service level agreements for all bill review clients
  • Address, mitigate and resolve all client issues related to the system and workflows
  • Recruit, develop and motivate and manage a staff of 15 analyst including training, performance, salary and compensation.
  • Work with the compliance team to determine the business impact of new regulations and define requirements for system modifications.
  • Work with claims EDI files for Network rate applications.
  • Define the requirements for existing clients to move to new Bill Review system determine testing needs and responsible for tracking and resolving the workflow/system related issues identified during testing.
  • Working knowledge of IVOS and Smart Advisor Systems.

Confidential

Business Systems Analyst

Responsibilities:

  • Gather business requirements
  • Document business requirements, project briefs, Test plans, and Flow charts.
  • Write test scripts, test plans and execute test cases for various system changes
  • Work with EDI files to troubleshoot and resolve data issues by reviewing 837 file layouts.
  • Work with technical staff to resolve file failure issues.
  • Collaborate with IT staff and business analysts to find solutions for customer needs and system infrastructure.
  • Provide direction to junior members of the team.
  • Mentor new hires and provide training as needed.
  • Review business data reports to determine the patterns and provide management team with recommendation for system related enhancements and solutions.

Confidential, West Sacramento, CA

Manager

Responsibilities:

  • Assume responsibility for day-to-day operation of Workers’ Compensation Technical Operations’ Team.
  • Build and administer business plans to meet or exceed goals for the department.
  • Recruit, develop and motivate the staff including communication on variety of personnel actions such as employment, termination, performance reviews, salary reviews, and disciplinary actions.
  • Managed client Issues including workflow, status updates and production delivery dates.
  • Provide input into development of department budget; manage budget and control expense while meeting operations, financial and service requirements.
  • Review system change specifications, review results and sign-off on system changes.

Confidential, West Sacramento, CA

Senior Workers’ Compensation Fee Schedule Analyst

Responsibilities:

  • Lead and supervise a team of 10 Analysts.
  • Act as liaison between customer support and the analysts on Operations Team.
  • Manage projects for system enhancements.
  • Attend Workers’ Compensation seminars for fee schedule held by the state boards.
  • Implement more complex rules for multiple states.
  • Act as a consultant to the junior analysts on the team.
  • Manage client issues related to system infrastructure.

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