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Click here or scroll down to respond to this candidateCandidate's Name
Street Address Sparrow Branch Circle PHONE NUMBER AVAILABLESt. Johns, FL Street Address EMAIL AVAILABLEA top-performing professional credited with combining insurance operations, customer service and management expertise to deliver substantial revenue growth in highly competitive business markets. Strong expertise in client management, problem solving and operational team development. Highly accomplished in process development and ability to build and maintain relationships. Skillful in allocating and coordinating resources.Areas of ExpertiseTeam ManagementOperational ManagementStrategic Planning/AnalysisIndustry NetworkingLeadership & MentoringCompetitive IntelligenceCustomer Service & RelationshipsSelf-Management & Problem SolvingCommunicationOperational StandardsBudgets & Service LevelsQuality & ProductivityKey Skills AssessmentStrategic Management Performance Develops and implements strategic and tactical strategies for operational management and successful employee performance.Team Management Committed to building internal teams through the exchange of knowledge, experience, and goal sharing to optimize strategies and customer service.Professional ExperienceFirst Citizens Bank, Jacksonville, FLSenior Relationships Specailist III (09/2023- present)AmeriHealth Caritas, Jacksonville, FLSupervisor Claims (11/2019- 3/2023)Responsible for carrying out the plans and daily operations of Claims unit(s). Knowledgeable in workflow productivity and provides leadership to the staff. Ensures that staff receives appropriate orientation and training to organizational and departmental policies and procedures and ensures that staff have the expertise to perform assigned dutiesProvides oversight and coordination of KMHP programs in accordance with applicable statutory provisions and complies with URAC, NCQA, DPW and federal requirements, Health Choices contract, and established policies and administrative procedures.Monitors case load assignments and makes appropriate adjustments based on staff experience, severity of cases and type of intervention(s) required. Provides coaching and counseling to improve productivity within the scope of HR policies and procedures.Functions as a member of the interview team in assessing candidates and ensures that minimal qualifications are met. Participates in training and education of new and existing staff.Works collaboratively with the Manager to prepare reports and conduct analysis of operations/services as required by departmental, corporate, and/or regulatory requirements.Performs quality audits per KMHP policy for assigned staff. Shares audit results with associates and provides necessary education and counseling to improve performance.Acts as a liaison with internal and external business partners to promote customer service, quality administration of health care benefits, and advocacy for members rights.Completes annual performance evaluations of all assigned staff. Completes evaluations using objective and measurable performance measures. Completes evaluations on time. Develops, implements, and monitors associates placed on performance improvement plans under the direction of the Manager.Maintains awareness of KMHP Policy and Procedures affecting Claims Unit.Acts as a liaison between Clinical Services and Operation Claims Department and works to resolve all potential and actual claims issues identified. Investigates and implements corrective action for weekly IMAX and Utilization Management Interface (UMI) Authorization Error Reports for lines of business 100, 500 and 528.Acts as project lead on projects as assigned by Department Director.Assists with the development of Policies and Procedures, and Standard Operating Procedures (SOPs).Works with appropriate supervisors/managers to evaluate the performance of staffSupports an environment that fosters leadership, teamwork, cooperation, respect and diversity. Establishes and maintains positive communication and professional demeanor with KMHP employees and members, and providers at all times. Demonstrates and supports commitment to corporate goals and objectivesMaintains current knowledge of computers, systems, and applications that impact the efficiency and quality of services of Clinical Services.Performs other related duties and projects as assigned.Adheres to KMHP policies and procedures.First Coast Service Options ( Medicare Administrator) Blue Cross & Blue Shield of Florida, Jacksonville, FLService Manager II (2006 8/2019)Effectively manages a team of 20+ provider relations customer service associates while tracking and promoting the success of employees through coaching and quarterly reviews.Set and monitored employee goals while giving monthly feedback on successes and areas of improvement.Ensures the customer contact with service representatives is without extreme variation while exhibiting integrity and decisiveness; inspiring confidence in employees.Mentors and motivates staff to achieve objectives and responsibilities with clear and specific expectations to obtain commitment from employees, peers, and clients.Resolves conflict through negotiation and takes ownership of team issues and follows through to closure.Makes decisions and considering the risks within scope of influence as well as all business partners involved.Develops training curriculum for support staff while openly sharing skills and knowledge with others.Demonstrates a strong desire to see the team or department achieve goals.Worked to develop and maintain productive relationships with customers, peers and business partners (Virgin Islands and Puerto Rico) while also identifying issues and addressing or resolving escalated customer concerns.Understands company goals and customer needs and provides a high level of crisis control and conflict resolution.Worked collaboratively with customers and partners, internal and external, to insure the needs of the business were met.Reported the company and department services and production accurately on a monthly and yearly basis.Objectively identified and analyze problems, evaluated alternatives, and recommend solutions.Actively participated in workgroups, sessions, and discussions to supports team decisions.Worked to develop and maintain productive relationships with peers and business partners.Conducted CMS rediness audits; supported claims, enrollmeent and customer service.Clinical Support Analyst- Pre- certification Medical review, Blue Cross & Blue Shield of Florida, Jacksonville, FL (2001 2006)Served as a liaison between Provider Community and Florida Blue.Ensured all paperwork and data was processed correctly in system for treatment and/or surgery.Interpreted ICD-9, CPT coding and DRG pricing.Coordinated benefits for all lines of business, verbal and written, to insure the accurate processing of PPO, HMO, and POS claimsCommunicated with patients and physicians to determine treatment requirementsInteracted with FEP and NASCO systemsAdjustments Examiner- State Account, Blue Cross & Blue Shield of Florida, Jacksonville, FL (1997 2001)Maintained control on all projects/assignments/responsibilities and monitored all assignments to insure timelines were being followed and escalated appropriately if additional recourses were required.Identified and corrected allocation issues within multiple projects, successfully managing multiple tasks and priorities.Obtained a clear understanding of projects, task assignments and desired outcome while working independently and understanding the needs of the business.Creatively resolved problems and was not confined by the way things have always been done.Education & TrainingME- Curriculum and InstructionUrban Teaching and Leadership ConcentrationLOUISIANA STATE UNIVERSITY SHREVEPORT6/26/2022Bachelor of Arts & Science Operational Management & Supervision,FLORIDA STATE COLLEGE Jacksonville, FloridaCOPC Customer Operations Performance Center Certified Coordinator,CERTIFICATION TRAINING Ponte Vedra, FloridaFCSO Leadership Certification,BLUE COSS BLUE SHIELD Jacksonville, FloridaSix Sigma Yellow Belt Certification,BLUE COSS BLUE SHIELD Jacksonville, FloridaResident Insurance License -06-20 - ADJUSTER - ALL LINESLicense Number : G025969Technology KnowledgeMCSDT,MCS, PECOS Systems, Availity, PETS, FISS, Verint, FacetsMicrosoft Office: Word, Excel, PowerPoint, Project, Visio |
