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Skills

  • Project organization
  • Relationship development
  • Business operations
  • Interpersonal communication skills
  • Customer service
  • Stakeholder collaboration
  • Advanced claims review techniques
  • Performance Metrics Tracking
  • Denial case resolution
  • Appeals performance analysis

Work Experiences

  • Weighed support and opposition to proposals by evaluating physical and digital records, testimony, and reports.
  • Acted as a key liaison between customer success and external stakeholders.
  • Acted as a key liaison between sales and external stakeholders, resolving disputes that represented 15 in potential liabilities.
  • Conducted root-cause analysis on over 10 resolved appeals.
  • Authored detailed appeals case reviews that served as benchmark learning materials for the broader organization, improving onboarding efficiency.
  • Contributed issue knowledge and key expertise in two years meetings focused on strategic planning concerns.
  • Collaborated with method to create an appeals resolution dashboard, enhancing visibility and decision-making for senior leadership.
  • Solved method issues, improved operations, and provided excellent customer service.
  • Oversaw the quality assurance program, which included on-site assessments, internal audits, and customer surveys.
  • Achieved faster resolutions.

Summaries

  • Achieved results in just 10 months.
  • Clear understanding of stakeholder engagement and team leadership as well as stakeholder engagement training.
  • Collaborated with stakeholders.
  • Capable of managing appeals in Japanese, leveraging multilingual proficiency to assist diverse teams in reaching timely and informed resolutions.
  • Excellent track record of resolving issues, increasing customer satisfaction, and driving overall operational improvements.
  • Proven leadership, operational excellence, and organizational development skills, as well as a thorough understanding of the metric business.
  • Comprehensive understanding of performance metrics tracking and appeals efficiency enhancements, consistently achieving or exceeding resolution goals by 54%-plus.
  • Consistently met performance targets by 53%.
  • Advanced analytical abilities.
  • Aptitude for data analysis.

Accomplishments

  • Used Microsoft Excel to develop inventory tracking spreadsheets.
  • Developed and implemented appeals process improvements that resulted in a savings of 9 in operational costs over three years.
  • Led cross-functional initiatives with method, enhancing collaboration and improving appeals processing efficiency by 69%.
  • Optimized interdepartmental communications between appeals, compliance, and legal teams, reducing duplicate work and cutting appeals review time by 6 hours per case.
  • Reduced appeals cycle time by performing deep-dive analytical assessments and implementing immediate corrective actions.
  • Decreased appeals backlog by 66% through a focused process optimization effort, reducing case resolution time by 16 days.
  • Mentored 17 junior analysts on correct appeals evaluation procedures, fostering leadership within the team and boosting success rates by 43% over three years.
  • Led a technology upgrade project that streamlined the appeals case intake system, reducing data entry time by 41%.
  • Designed a metrics tracking tool that identified bottlenecks in incoming appeals, increasing case resolution speed by 18% over the previous quarter.
  • Established a comprehensive appeals reporting system, creating real-time dashboards in Jira that enhanced decision-making and operational oversight.

Affiliations

  • Member, Financial Executives Healthcare Care Council (FEHCC)
  • Certification, Certified Professional in Healthcare Quality (CPHQ)
  • Member, Healthcare Financial Management Association (HFMA)
  • Membership, National Association of Insurance Commissioners (NAIC)
  • Contributor, Healthcare Quality Improvement Collaborative (HQIC)
  • Member, National Association of Managed Care Regulators (NAMCR)
  • Freemason
  • Board Member, National Appeals and Dispute Resolution Association (NADRA)
  • Panel Speaker, Managed Care Compliance Conference 2022
  • Participant, Utilization Review Accreditation Commission (URAC) Educational Programs

Certifications

  • Certified Specialist in Managed Care (CSMC)
  • Microsoft Certified Systems Engineer (MCSE)
  • American Academy of Professional Coders (AAPC) Certification
  • Google Certified Professional Cloud Architect
  • Healthcare Appeals and Grievances Professional (HAGP) Certification
  • Certified Internal Auditor (CIA)
  • Appeals Specialist Certification from Cedar Works
  • ICD-10-CM/PCS Coder Certification
  • Healthcare Financial Management Association (HFMA) Certified Revenue Cycle Representative (CRCR)
  • Certified Business Analysis Professional (CBAP)

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