Provider Experience Director II

• Jul 2022 - Present

Manager II - Member Program Management

• Apr 2021 - Jul 2022

Project Manager

• Mar 2020 - Apr 2021

Project Leader

• Oct 2018 - Mar 2020

– Develop and manage Social Determinants of Health Sharepoints and data capture methods– Implement 11 subcontractors onto the Anthem platform in accordance with AHCA and CMS regulations– Manage the reductions of private duty nursing rates in an effort to remain competitive within the Florida market– Lead capitation reconciliation initiative to correct all provider data issues and collect system caused overpayments– Handle post integration issues to prevent member abrasion, liquidated damages, fines, and state/federal complaints Show less

Business Change Advisor

• Sep 2017 - Sep 2018

– Served as the claims subject matter expert for CMS and AHCA audits– Facilitated the Invitation to Negotiate (ITN) bid to re-procure in the Florida market for 3 health plans– Managed cost saving initiatives such as EAPG pricing, CCI edits, DRG Pricer, and iHealth edits– Launched AI initiative of 100 macro built robots to reduce COBA inventory and increase key performance indicators

Operations Expert

• Aug 2016 - Sep 2017

– Produced key performance indicators for all Operational areas and served as a data analysis expert for Claims, Configuration, Credentialing, Enrollment, and Provider Administration departments– Created and submitted monthly CMS Organization Determination, Appeals and Grievances Tables 3 and 4 reports– Led the implementation of Macess, a business performance program that increased daily claims production

Claims Examiner

• Aug 2015 - Aug 2016

– Reviewed and adjudicated incoming physician and hospital claims in accordance with both state and federal regulations– Adjusted and reprocessed claims due to provider disputes upon completion of research and historical findings– Managed inventory for the DME and Home Health teams to remain within contractual service level agreements

Home Health Care Biller - Ambassador

• Aug 2014 - Jul 2015

- Audited invoices received and made sure all required documentation and discipline was correct while maintaining patient confidentiality in accordance to HIPAA. - Billed and processed all fee for service invoices in an accurate and timely many for three different contacts in both HCFA and UB04 - Transmitted claims both electronically through Emdeon and scanned. - Understood rules, regulations, and appeal process in accordance to health insurance billing coverage and collection process - Represented the Revenue Cycle department in a company wide team created to enhance employee work experience as well as communicate issues to upper management. Show less

Certified Nursing Assistant

• Jun 2013 - Jul 2014

• Assist patients in daily chores such as bathing, eating, and dressing • Render patient care by checking vital signs and performing glucose checks • Notifying nurses on patients’ health statuses and helping alter the patients needs for full comfort • Assist patients in daily chores such as bathing, eating, and dressing • Render patient care by checking vital signs and performing glucose checks • Notifying nurses on patients’ health statuses and helping alter the patients needs for full comfort

Health Promotion Assistant

• Sep 2011 - Apr 2013

• Delivered quality wellness services and health promotion programs such in topics such as sexual health, smoking cessation, and nutrition to students and faculty throughout the Florida State University • Attended to front desk duties including checking in patients, answering phone calls, and making appointments using eCW • Delivered quality wellness services and health promotion programs such in topics such as sexual health, smoking cessation, and nutrition to students and faculty throughout the Florida State University • Attended to front desk duties including checking in patients, answering phone calls, and making appointments using eCW

Billing Clerk

• Oct 2009 - Aug 2010

• Billed medical insurances the coverage for patients’ durable medical equipment using Pacesetter • Ensure patients prescriptions were correct and provided proper equipment to their homes in agreement with their physician • Billed medical insurances the coverage for patients’ durable medical equipment using Pacesetter • Ensure patients prescriptions were correct and provided proper equipment to their homes in agreement with their physician