Quality Control Resume Profile

Skills/Qualities

Experience

Confidential

Quality Control Specialist

Evaluated completed NYS Medicaid, Family Health Plus, and Family Planning Benefit Program renewal applications and missing information documents for accuracy in accordance with Federal and State regulations and department approved policies and procedures
Entered and submitted error findings using department specific Quality Control tools
Completed the renewal processing for all inaccurate renewal applications and missing information tasks reviewed
Provided feedback to quality control supervisor s giving specific reasons for variances, and respond to dispute findings when necessary
Met and maintained quality control standards as set by the quality control department
Remained up-to-date on policies and procedures for renewal processing

Confidential

Quality Control Specialist

Performed quality review of all membership enrollment specialists, senior enrollment specialists, and provider enrollment specialists
Maintained individual quality scores and information using Excel spreadsheets
Supplied necessary reports for management measurement and review
Supplied feedback on quality trends and training needs to the training department
Reported directly to the Director of Membership Billing Department
Assisted with the setup of the new Quality Control Department for the Membership Billing Department
Assisted with the development of all forms, scoring setup, and policy and procedures regarding quality control

Confidential

Claims Examiner

Responsible for processing and approving various types of medical claims for payment
Assigned to perform pre-review of all claims over all claims examiners' allowed payment dollar limits
Handled work for high priority groups resolving sensitive and immediate issues
Trained examiners in new types of claim categories on a regular basis
Assisted supervisor in all areas of claims processing including quality control issues, training, PR concerns, complicated claim issues, priority reports, and scheduling of daily work for the unit
Assisted the Provider Services Unit by answering incoming provider phone calls regarding their questions, when needed
Maintained superior ratings on all quality control and production requirements
Used Excel and Microsoft Word, as well as Outlook as required

Confidential

Word Processor

Responsible for preparing medical journals for publication by inputting text along with publishing codes using PCs and Wordstar word processing applications
Performed under very strict deadlines and required extremely high accuracy
Job was performed from home which required a great deal of independence, self-motivation, and discipline