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Medicare Complaint Case Manager Resume

Roanoke, VirginiA

SUMMARY:

  • 11 years of insurance knowledge including Medicare and Medicaid, Commercial, and Local and State policies
  • Ability to complete data analysis, quality insurance, with knowledge of physician and hospital reimbursement methodology
  • Dedicated to building a highly motivated teams while maximizing skills of their roles within the organization
  • Proficient with Cosmos, Nice, Care Core, AS400, FACETS, PBM Pharmacy Processing software
  • Customer - focused office manager with care center experience and appeal specialist with over 12 years’ experience in medical office operations, and Medicare Prescription Drug/Medicare Advantage/Complete Programs
  • Performs effectively in fast-paced environments with the ability to lead and motivate employees
  • Resourceful and detail oriented; skilled multiple tasker and problem solver
  • Knowledge of HCPC, ICD-10 codes, Revenue Codes, Confidential processing
  • Effectively balancing employee needs with company policies and procedures
  • Proficient knowledge of letter writing in accordance with CMS guidelines, and company polices
  • Knowledge of the CMS Part C and D environment in relations to Health Plans, Insurers, Provider, Vendor and Facilities and CMS Part C & D program requirement including reporting
  • Understanding of all CMS Medicare and Medicaid and Part C& D requirement including manuals, guidelines and Codes of Federal Regulations, Fraud Waste and Abuse
  • 3 years’ experience performing Human Resources duties, administration, employee services, training, supervision, employee counseling, budgets, retention
  • Experienced in compensation and benefits, personnel and pay management/administration

WORK EXPERIENCE:

Confidential, Roanoke, Virginia

Medicare Complaint Case Manager

Responsibilities:

  • Conduct/utilize research/investigations/overpayments/complaints, and appeals for Centers for Medicare and Medicaid Services/Providers, identification to determine accuracy of claims payment (prospectively and retrospectively) for complete accuracy of processing under the Medicare and Medicaid realm for Medicare Advantage/Supplemental/Community State Plans, with claims processing for medical, dental, prescription drug benefits, behavior health/Skilled/Rehab Facilities
  • Work with payers/providers/patients/CMS to review complaint to ensure accuracy
  • Document and communicate outcomes of claims investigations/overpayment/denials reviews to applicable stakeholders
  • Continuous quality analyst improvement while rendering final decision based on analysis according to procedure, state and federal guidelines, benefit plan guidelines, internal policies and work flows
  • Provide subject matter expertise as a lead educator/Trainer to address maximum capacity of coordinator skills, while developing training literature reflective to rendering results from Federal guidelines that are implemented within the organization
  • Handle Provider appeals, risk management, including incidents, mortalities while cost effective processing payment under data processing within COSMOS/FACETS/NICE/California medical groups/Optum pharmacy processing
  • Serve as a liaison regarding complaint received from outside organizations, Congress, Centers for Medicare and Medicaid Services, State Department, Department of Insurance, Better Business Bureau
  • Maintaining confidently of members, physicians, employee information, with consistently maintaining accurate rate of 95% as documented by routine CMS audits, along with department and corporate goals, and CMS star rating
  • Maintain a database of appeal that can be used to properly report to the Centers for Medicare and Medicaid Services

Appeals & Grievance Coordinator

Confidential

Responsibilities:

  • Assure prompt and proper handling of appeals and grievance requests
  • Responsible for assisting managers in the configuration and continuing maintenance of software used to facilitate appeal/grievance tracking and processing
  • Work with payers/providers/patients/CMS to review complaint to ensure accuracy
  • Document and communicate outcomes of claims investigations/overpayment/denials reviews to applicable stakeholders
  • Continuous quality analyst improvement while rendering final decision based on analysis according to procedure, state and federal guidelines, benefit plan guidelines, internal policies and work flows
  • Construct finalization notices to Centers or Medicare and Medicaid Services and Maximus Federal Services, and beneficiaries to provide a decision of rendered for uphold, and denials of services rendered

Traveling Instructional Design Trainer

Confidential

Responsibilities:

  • Primary responsibility was effectively designing, development and delivery of training programs, material
  • Conducting needs analysis for channel, product and business processes as well as designing, developing and delivering learning activities and communication that promoted overall growth and performance
  • Responsible for evaluating learning outcomes to ensure effectiveness of program and recommending and implementing medication if necessary
  • Proficient in designing and delivering instructor-led, virtual and self-paced solutions on training
  • Responsibilities of applying innovative and creative strategies such as web based tutorials, documentation procedures, audio, and video
  • Proficient in Microsoft Office Suite program including Word, Excel, PowerPoint, and OneNote
  • Created effective relationship building across business groups, to be able to provide a storyline, articulate and captivate, the trainees, while adapting to all different learning types
  • Worked with different department to ensure the efficiency of new skills were implemented properly under the Centers for Medicare and Medicaid Guidelines
  • Traveling care associate for vendor support, Medicare Events, AARP conventions, during Medicare Open Enrollment Period to assist in ensuring provider relations for the organization

Customer Relations Subject Matter Expert

Confidential

Responsibilities:

  • The role diagnoses and resolves problems using documented procedure, and checklist, handles problem recognition, research isolation and resolution steps
  • Responsible for answering patients, providers, Medicare, commercial, employer group, SHIP, offices calls and researching and resolving issues in order to receive Maximus profitability for clients
  • Review claims to make sure that payer specific billing requirement are met, follow-up on billing determines and applies appropriate adjustments, answers inquires and update accounts as necessary
  • Respond to and resolve on the first call, and handling caller needs such as benefits eligibility and claims, financial spending accounts and correspondence
  • Guide and educate customers about the fundamental and benefits of consumer-driven health care topics to include managing their health and well-being by selecting the best benefit plan options, while helping to maximizing the value of their health plan benefit and choosing a qualify care provider
  • Intervene with care provider on behalf of the customer to assist with appointment scheduling or connections with internal specialist for assistance when needed
  • Meet the performance goals established for the position in the area of efficiency, call quality, customer satisfaction, and first call resolution
  • Assisting other advocates with answering question for complex issues, and assisting in finding a resolution, while providing expert solution to help with limit of conflict with management

Human Resource Generalist

Confidential, Roanoke, Virginia

Responsibilities:

  • Direct personnel, training, and labor related activities
  • Efficient in PeopleSoft, Taleo, Recruiting
  • Advice managers of on organizational policy matters, under I-9 processes
  • Identify staffing vacancies and recruit, interview, and selected applicants
  • Promoting equality and diversity in the recruitment process
  • Ensuring that all company policies and procedures are up to date with current employment law
  • Managing payroll operations
  • Controlling cost and ensuring that they do not exceed payroll budget
  • Investing disciplinary and grievance matters
  • Knowledge of recruiting, interviewing, hiring, counseling and termination practices including legal compliance and internal processes
  • Managed and controlled cash flow - conduct bank transactions, and Maintained branch safety and security standards
  • Filed personal records to include receipts, taxes, phone records and supplies for reporting year
  • Knowledge of inventory management and merchandising
  • Accounts payable and receivable

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