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Director Of Claims Operations & Payment Integrity Resume

Lewiston, MainE


  • Bringing 26+ years of Claims Processing, Claims Recovery for Medical and Pharmacy, Coordination of Benefits (COB), Medicare Secondary Payer (MSP) experience, and Medicare & Medicaid regulatory and compliance. Two (2) years of Health Care Exchange - Affordable Care Act (ACA).
  • Claims processing and COB claims processing
  • Claims audit, appeal and adjustment
  • MSP & Coordination of Benefits rules and guidelines
  • MSP Premium Adjustment process and recovery
  • Proficient in CMS compliance and regulatory in Claims, Enrollment and COB MSP Part C and Part D
  • Medicare Advantage and/or Medicare Prescription Drug Plans (MAPD/PDP) requirements
  • MA/MAPD/PDP Medicare claims recovery (Medical & Pharmacy)
  • Proficient in all claims processing, MSP processing and claims appeal & grievances
  • Manage Claims and MSP CMS Plan Organization and Financial Audits
  • Initiate and manage cross-functional teams and multi-disciplinary projects
  • CMS guidelines, Federal Regulations, CMS Audits guidelines, CMS Enrollment, MSP & Claims Manual requirements and CMS chapters (MSP/Claims Processing/CMS Compliance)
  • NCQA and HCFA guidelines
  • Electronic Correspondence Referral System (ECRS) submission
  • Project development and various stages of system testing, Unit, Product (System), Integrations, Regression, and User Acceptance Testing
  • Investigation and problem solving
  • Claims Adjustments, Audit, Editing, Projects and Initiatives, Reporting, Coordination of Benefits, Encounters and Production
  • Resolve CMS Grievance and Adjustment appeals and resolution process, including claims CMS CTM complaints.
  • Claims processing & recovery
  • CDAG&ODAG CMS claims auditing and departmental monitoring
  • Claims adjustments & retro recovery
  • Coordination of Benefits (COB), including State, Federal and Third Party Liabilities and COB regulations and guidelines
  • Quality Assurance (QA) internal auditing
  • Microsoft Office application, (i.e. Access, PowerPoint, Excel, Visio & Microsoft word.)
  • Facets software application, IKA gateway, Pega application and other system.
  • ESRD MSP eligibility requirements
  • Enrollment OHI eligibility validation.
  • Enrollment reporting (MMSEA- SECT 111 Mandatory Reporting & COBA-CMS (Crossover claims) Reporting
  • ECRS submission (Flat File Creation & Web Flat File Submission)
  • Design staff work processes, policies and procedures
  • Staff training and supervision
  • Project planning management and delegate tasks
  • Team improvements and staff development
  • Strong critical thinking, decision making and problem solving skills
  • Manage day to day department operations
  • Coaching, counseling and evaluation of employee’s performance
  • Maintains and promotes organizational values
  • Solving, investigation and critical thinking
  • Establish and maintain positive and effective work environments
  • Maintain and support required department production for quality, quantity and completion of work
  • Review and advise claims complexity and sensitivity issue
  • Recommend and assist FDR acquisition of vendors and other tools or equipment, for optimize departmental resources and performance and output
  • (SME) Subject Matter Expert Government MSP, COB, CMS MSP Government Enrollment, Dual Eligibility & Claims process


Confidential, Lewiston, Maine

Director of Claims Operations & Payment Integrity


  • Direct, manage and coordinate new system implementation.
  • Maintains critical information on claims databases.
  • Synchronize data among operational and claims system
  • Identify improvement opportunities and establish policies, operating procedures.
  • Responsible for leading, managing, and providing oversight for all hands-on operational aspects and activities of various functional areas within the Plan.
  • Direct the strategic analysis and accuracy of Claims processes and ensure compliance with state regulations and/or provider contracts Support operation application rules apply to each database. Validate data housed on databases.
  • Ensure adherence to business and system requirements.
  • Establish liaison to claims department when it’s pertain to customer, benefit contract, contracting, prior authorization, fee schedule, and other business requirements.
  • Leverage automation to achieve desired results by reviewing and implementing new processes and technological tools.
  • Oversee data implementation, collection, validation and analysis of data to deliver business solutions ensuring claims payment accuracy, efficiency and quality.
  • Monitor performance, evaluate, develop and implement business solutions to improve process and quality gaps.
  • Identify improvement opportunities and promote change through sharing of best practices

Confidential, Detroit, MI

COB Medicare Manager / Gov’t Enrollment / Coordination of Benefit (COB) Operation


  • Responsible for overseeing complex high-level claim review, and identifies areas of overpayment.
  • Manage and oversees claim auditing processes and identify process improvement opportunities.
  • Oversees business partner claims processing and auditing and maintain the standards quality and accuracy including claims Fraud, Waste and Abuse monitoring.
  • Develop, secure approval of, and implement policies, procedures, and protocols necessary to achieve short and long-term goals and objectives for Government Enrollment & COB Department.
  • Develop and establish data maintenance, MSP: reconciliation, reporting, analysis, trending, project management. Support reconciliation requirements for Medicare membership enrolled in a government program and provide a project management activity that is not limited to a sound and effective implementation of all system related interfaces, development of an infrastructure that support project initiatives, process workflows, relevant and meaningful data reporting analysis, and in addition to timely and accurate migration of system enhancements.
  • Manage, maintain, and ensure department enrollment group, individual, Medicare Application and COB processes. CMS Claims or COB Appeal and resolution process, including CMS CTM complaints and Clams Grievance.
  • Manage CMS regulation and MA/PDP Plan requirements for Medicare Secondary Payer (MSP) and provide support to Claims Division (CMS Claims guidelines & Enrollment guidelines).
  • Manage, maintain, and ensure compliance with departmental and corporate based upon the CMS guidelines.
  • Ensures compliance with all regulatory and accreditation standards and updates policies and procedures to reflect changes in regulatory requirements.
  • Manage Plan/CMS crossover claims and COB Agreement reporting, CMS MSP Demand Request, Claims Retro Active Recovery for Medical & Pharmacy.
  • Develop and establish data maintenance Government Enrollment: Plan File Processing Responsibilities DTRR (daily) CMS submission and monthly MARx reporting including disenrollment, Low Income Subsidy (LIS), Late Enrollment, and (PDP) Part D Plan enrollment; training and implementation of process.
  • Oversee the development and implementation of internal/external controls to ensure administrative cost-effectiveness, accurate and correct coverage determinations in support of CMS Part C, Part D and MSP regulations.
  • Manage day to day Medicare Advantage operational issues and facilitate resolution if applicable. Provide staff with direction and guidance in making accurate determinations and addressing system or workflow concerns. Act as a Liaison between departments and other external entity and CMS Government Agency.
  • Manages several subordinate employees in the assigned area(s). Responsible for the overall direction, coordination, and evaluation of the department. Carries out menagerie responsibilities in accordance with the organization's policies and applicable laws. Responsible for but not limited to interviewing, hiring, and training employees. Department planning, assigning, and directing work. Employee appraising performance, including mentoring, rewarding and disciplining employees. Provide management support by addressing complaints and resolving problems.
  • Establish department goals and objectives that support continuous quality improvement. Develop and maintain department system monitor, measure, and performance report and achievement for long-term goals and strategic initiatives that has impact Claims & Enrollment Division.
  • Manage and maintain CMS Department MSP reporting for COB, including ECRS, SEC111 Mandatory Reporting and COBA (Crossover Claims) and data maintenance for PBM (Pharmacy), MSP OHI, Dual coverage and CMS reporting.
  • Manage and responsible for the design, development, and system testing for any software upgrades & implementation, including testing with external vendors.

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