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

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.