Experience

Molina Health Care

• United States
• Insurance
• 1 - 100 Employee

• Senior Risk Adjustment Specialist

  • May 2017 - Present

• Risk Adjustment Specialist

  • May 2016 - May 2017

  Develops, implements, and manages all project plans related to initiatives to improve plan risk score performance.Monitors performance and evaluate results of risk adjustment initiatives.Manages relationships with external vendors assisting with risk adjustment initiatives.Oversees accuracy and distribution of documentation and reports required by vendors and internal departments.Assists with relationship building strategies and opportunities for financial growth through risk score improvement initiatives.Identifies, develops and implements provider/member programs specific to risk score improvement.Works closely with Provider Services staff to outreach and educate the provider network on proper coding practices.Knowledge/Skills/AbilitiesAdvanced knowledge of Microsoft Office inlcuding Outlook, Word and ExcelExcellent influencing and negotiating skillsExcellent organizational and time management skillsAbility to work individually or as part of a teamAbility to learn internal/external systemsInnovative thinker and ability to independently implement ideasExcellent verbal and written communication skillsAbility to abide by Molina’s policiesAbility to maintain attendance to support required quality and quantity of workMaintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA)Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers

• Supervisor of Enrollment Accounting

  • Feb 2015 - May 2016

  Accomplishing department objectives by managing staff, including daily production planning activities. Working collaborative with corporate IT to ensure daily/monthly eligibility files are loaded accurately and timely. Accomplish department objectives by managing staff; including daily production, direct over sight of staff in resolution of all errors during the eligibility loads, ID card generation, PCP auto assignment and exports process. Reconciliation files for daily enrollment eligibility. Ensure that all compliance measures are met with provider agreement timelines for all enrollment process including but not limited to: newborns, member reconciliation reports, eligibility loads and vendor extracts. Overseeing COB initiatives to maximize cost avoidance and cost recovery for claims. Attendance of Monthly MDHHS Enrollment meeting to ensure accurate processing of daily member files received. Track and trend changes as it affects Health Plan business needs on a daily basis.

• CSR/Enrollment Specialist/CSHCS Coordinator

  • Apr 2011 - Feb 2015

  Incoming Calls verification of benefits, assiting with appointments, tracking HEDIS statistics. Involved on day to day basis with setting up transportation services to ensure members get to needed appointments in a timely manner. Indentify member needs resolving all issues in a timely manner. Developing new alternatives to member satisfaction for a company as whole. Being able to reconize the needs of members and providers alike. As of September 2012 proceeding as an Enrollment Specialist II in the Enrollment Department. Becoming a key team member in establishing and coordinating needs for CSHCS members on a daily basis.



Total Health Care USA

• Account Manager/CSR

  • Oct 2006 - Jul 2010

  Maintaining Renewals for Commercial Groups, rates, providing insurance needs to fit company needs and size. Making innovative steps to maintaining a low cost for the companies as whole. Organizing and conducting open enrollment meetings. Ensuring employers have a ful understanding of their current year benefits. Also working in member services, providing accurate information to THC members. Benefits information, Provider listing, assuring that all records were maintained and accuratly updated on a day to day basis.



OCE

• Egypt
• Architecture and Planning
• 1 - 100 Employee

• Mail Clerk

  • 2004 - 2006



Ymca Camp Storer

• Horse Wrangler/Trainer

  • Jan 2003 - Jun 2004

  Provided Training for incoming Horses, provided lessons children 7-18. Management of horse herd of 65 horses. Providing feed, water, medical attention when needed. Tacking up 30+ horses on a day to day basis preparing campers for a postive experience suring their visits to YMCA Camp Storer. Provided Training for incoming Horses, provided lessons children 7-18. Management of horse herd of 65 horses. Providing feed, water, medical attention when needed. Tacking up 30+ horses on a day to day basis preparing campers for a postive experience suring their visits to YMCA Camp Storer.



Jackson Staffing

• United States

• CSR

  • 2001 - 2003

  Establishing a excellent relationship with our members. Assisted with all billing issues, but limited to payment arrangements, scheduled bill pay dates, also making sure data entry of payments were applied accordingly.Committing to making sure all monthly and weekly goals were met. Always maintaining an above average performance record on a month to month basis. Establishing a excellent relationship with our members. Assisted with all billing issues, but limited to payment arrangements, scheduled bill pay dates, also making sure data entry of payments were applied accordingly.Committing to making sure all monthly and weekly goals were met. Always maintaining an above average performance record on a month to month basis.