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Skills

  • Reporting skills
  • Regulatory compliance
  • Problem resolution
  • Cost-saving contract negotiations
  • Multidisciplinary team collaboration
  • Process improvement
  • Care management program development
  • Training program development
  • Account management
  • Cost-benefit analysis for new programs

Work Experiences

  • Conducted root cause analysis for recurring claim discrepancies, instituting improvements that eliminated process error from future submissions.
  • Assisted in conducting cost-benefit analysis for the implementation of new managed care programs, demonstrating anticipated savings of $2.
  • Conducted comprehensive reviews of denied claims, enabling 68% successful appeals and reducing out-of-pocket costs for clients.
  • Conducted comprehensive reviews of denied claims.
  • Transported Power BI to several months customer locations.
  • Answered 15 calls per several months to help customers with their questions and concerns.
  • Had an excellent attendance record and was always on time for work.
  • Achieved a 72% decrease in call center volume.
  • Achieved a 23% reduction in errors.
  • Collaborated with a multidisciplinary team to address escalated claims issues, reducing complaint resolution time from one year to procedure.

Summaries

  • Dedicated to learning, growing, and succeeding in Miscellaneous.
  • Recognized for motivating management team members to achieve their goals and fostering innovative work environments.
  • With excellent planning and problem-solving abilities, I am organized, driven, and adaptable.
  • Adaptable Managed Care Representative.
  • Managed Care Representative is a multi-talented Managed Care Representative who is consistently rewarded for planning and operational improvements.
  • Achieved zero audit findings across 6 inspections.
  • Achieved a 29% decline in claims processing mistakes.
  • Managed Care Representative with 6 years of experience, dedicated to providing personalized, courteous service.
  • Achieved a 79% year-over-year retention rate.
  • Hardworking Managed Care Representative with 10 years of telecommuting experience meeting customer needs.

Accomplishments

  • Increased training participation by 19% for new hires, significantly enhancing the claims team's overall performance.
  • Mentored junior team members on claims procedures, reducing their onboarding time by one year and improving overall department productivity.
  • Streamlined invoice validation, reducing processing errors by 77% while maintaining adherence to health plan policies.
  • Used Microsoft Excel to develop inventory tracking spreadsheets.
  • Audited managed care operations on a monthly basis, identifying 7 issues in billing, which led to the recovery of $7 in overpayments.
  • Implemented auditing processes that reduced claim discrepancies for high-cost drugs by 16% compared to the previous fiscal year.
  • Developed and delivered training programs that increased staff compliance with managed care protocols by 25%, improving efficiency.
  • Drove a 33% increase in the first-time accuracy rate of claim submissions through comprehensive staff training and process documentation.
  • Assisted in contract renegotiations that delivered cost savings of $17 over one year for healthcare network reimbursements.
  • Worked in collaboration with payment integrity teams to recover $16 in overpaid reimbursements from managed care agreements.

Affiliations

  • Urban Health Initiative - Managed Care Task Force Member in 2020, addressing underserved populations' access to care
  • Association of Information Technology Professionals
  • America’s Health Insurance Plans (AHIP) - Completed procedure in 2021
  • National PACE Association (NPA) - Regular attendee of workshops focusing on managed care for elderly populations
  • Association for Healthcare Resource & Materials Management (AHRMM) - Certified in framework in 2017
  • National Association of Healthcare Revenue Integrity (NAHRI) - Engaged in benchmarking projects in 2022
  • Jaycees
  • Association for Computing Machinery
  • Case Management Society of America (CMSA) - Collaborated in forums on claims processing and authorization
  • American Hospital Association (AHA) - Contributor to whitepapers on payer/provider relationship management in 2022

Certifications

  • Certified Case Manager (CCM)
  • Certified Population Health Manager (CPHM) by Summit Group
  • Certified Public Accountant (CPA)
  • Certificate in Managed Care Pharmacy (CMCP) by Brightline
  • CompTIA Network+
  • Case Management Administrator Certification (CMAC)
  • Certified HIPAA Privacy Expert (CHPE)
  • Salesforce
  • Cisco Certified Internetwork Expert (CCIE)
  • Certified Health Insurance Specialist (CHS)

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