Experience

BMG

• Food and Beverage Services
• 100 - 200 Employee

• Vice President of Operations

  • Jun 2012 - Present

  Report directly to the CEO. I am responsible for overseeing the day-to-day functions of the recovery Operations, lending full support to the overall company’s business needs, including but not limited to the loading and auditing of new contracts, and the validation of under-payments identified. • Implementation process for new clients • Manage client accounts • Load/ QC facility contracts in FileMaker • Validate/QA result files for accuracy in accordance with the facility contractual rates • Trend Audit files for best results • Track recovery progress by monitoring weekly reports • Follow-up with Payors on claim collections process • Responsible for all collection communication • Manage staff Goals and Objectives



Healthfirst

• New York, New York

• Assistant Director, Claims

  • Feb 2011 - May 2012

  Reported to the Director of Claims, I was responsible for day-to-day functions in the Front End Operations, Overpayment Recovery, Coordination of Benefits and Claims Long Term Care unit. • Responsible for the oversight and timely handling of all claims function. • Responsible for the oversight process and policy development, workflows, job-aids and controls to ensure special contractual limitations are adhered to in regards to the audit process. • Responsible for the oversight and timely handling of Underpayment/ Overpayment Recoveries contributing to the overpayments and underpayments of claims. This includes trending and analyzing system configurations contributing to Underpayments/Overpayments.



Universal American Corporation, CHCS

• Pensacola, Florida

• Vice President, Claims Cost Containment and Recovery

  • Jul 2007 - Dec 2010

  Universal American Corporation is a specialty health and life insurance holding company offering a comprehensive and affordable array of healthcare products, including a broad range of traditional health insurance, Medicare managed care products, and Medicare prescription drug benefits coverage to millions of Medicare beneficiaries. VP, Claims Cost Containment and Recovery Reported directly to Senior Vice President of Claims Operations; oversaw a global workforce with directly supervision of 75 within Claims Recovery Team on and offshore. Claims recovery adjustments completed for 2009 totaled 321,000, and collections processed for 2009 total $82,000,000.00. • Requested by CAO to investigate and resolve an unidentified refund check shortage issue: saved company more than $100k in less than one month through analysis of backlogged refund checks and cleared up all outstanding items. Shifted resources and created a now permanent 6-person team, and modified and created policies related to batching systems procedures to avoid like future issues. • Surpassed cost containment goal by $40M: Cost Containment unit was given an annual goal to recover $5mil for 2009. Led team to actual recovery amount of approximately $45M for 2009. This contributed to the creation of a formal recovery unit with a staff of 25 employees, formal Policies and Procedures, and formal Auditing and Training programs. • Recognized by Senior Management for improving Cost Containment team’s TAT and Accuracy for Payment Posting; reduced Administrative costs and reduced defects through root cause analysis of the various overpayment reasons. Informed Sr. Management of opportunities and improved the overall claims production performance.



Vista Healthplan

• Sunrise, FL

• Director, Claims Operations

  • Sep 1998 - Jan 2007

  Director, Claims Operations Reported to the Senior Vice President of Operations, provided leadership for a multi-functional, high production, service oriented staff of 50-100 associates. • Oversaw the overall daily operational functions of the Claims Processing and Claims Appeal units and ensured the regulatory and legal requirements for the claims and appeals process were met. • Reduced the overall appeals resolution time to 30 days, and implemented several system enhancements to reduce the number of pending/denied claims. • Increased service levels for the members and providers by conducting daily meetings with Grievance and Appeals and Provider Relations Departments. • Negotiated payments for services rendered by non-contracted providers, and reviewed daily reports to meet the regulatory requirements for timeliness of claims payments. Manager, Claims Quality Control, Cost Containment and Recovery and Provider Appeals Reported to the Director of Claims and managed a staff of 20 associates in the oversight of all recovery efforts, COB and TPL Cost Avoidance, Claims Adjustments, Macess and Electronic Claims Quality Control and Provider Grievances. • Improved total savings for organization by 250% in the first quarter 2000 compared to 1999. Manager, Data Management Reported to Director of Data Management and managed a staff of 10 Associates. • Implemented standards for entry of configuration parameters to improve consistency and overall performance of system. • Facilitated bi-weekly meetings with the Claims Department to identify issues to increase automation of the manual processes. • Developed a Quality Control program for department to insure accuracy of configuration. • Coordinated configuration audit that reduced overpayments by 15%. • Established and implemented training sessions for Provider Relations to improve contracting efforts. • Reached and maintained a 5 day turnaround on all configuration requests.



Tenet Network Management

• Florida

• Claims Manager

  • 1997 - 1998



Physician Corporation of America

• Miami, FL

• Claims Service Supervisor

  • 1994 - 1997