Experience

Care N' Care Insurance Company

• United States
• Insurance
• 1 - 100 Employee

• Business Solutions & Vendor Relations Specialist

  • Nov 2022 - Present

  • Manage daily relationships with benefit vendor and business solutions system partners. • Perform routine monitoring and auditing activities to ensure optimal oversight and monitoring of benefit vendor and business solution system partners. • Coordinate routine operational calls with assigned partners to oversee performance, ensure compliance with all regulatory requirements and contractual obligations, and identify and resolve any identified deficiencies. • Ensure benefit vendor and business solution partners provide reports and data needed to track key performance indicators and adherence to service level agreements. • Prepare presentations and worksheets to be shared with department leadership to convey benefit vendor and business solutions system partners performance. • Evaluate benefit vendor and business solution system partners’ performance to support paths to improvement in processes, efficiency, and effectiveness. • Evaluate and troubleshoot routine operational challenges. • Collaborate with other team specialists to address gaps in staffing to minimize business risk. • Coordinate and operationalize intermittent and ongoing partner functions and maintenance. • Provide support for business solution applications and security administration



Southwestern Health Resources

• United States
• Hospitals and Health Care
• 200 - 300 Employee

• Corporate Compliance Auditor, Medicare Advantage Operations

  • Jun 2022 - Nov 2022

  • Work as an individual contributor, reporting to Director of Operations. • Review operational processes for teams across the board at health plan, identify areas of improvement and gaps, work to create functional flows, incorporate flows into teams, monitor and update as needed. • Provide feedback to teams and leadership on identified risks and resolutions. • Complete and maintain detailed reports and documentation of audits including methodology, discrepancies, and trending analysis. • Cross- organizational communication to obtain necessary information. • Review of payment integrity, claims processes, enrollment, and other operation departments. Validate that all letters from plan are compliant.



Wendy McKinley/Dave Watson LLC

• Fort Worth, Texas, United States

• Home Health Care Coordinator

  • Dec 2021 - Sep 2022

  Working directly with family to provide full in-home care through the Medicaid SSI program to special needs children. Providing all billing documentation to family for sign off on. Creating a plan of care for child with family and the rest of the healthcare team to follow on a daily/weekly basis. Outlining goals for the child to meet and working with child to achieve. Providing guidance to family on insurance and assistance programs that are provided. Completing all paperwork and submitting it back to office for processing.



Care N' Care Insurance Company

• United States
• Insurance
• 1 - 100 Employee

• Enrollment Analyst

  • Sep 2021 - Jun 2022

  Leads supervisory initiatives within the enrollment team. Review enrollment processes and procedures, updating them to fit CMS and plan standard. Tracking ongoing issues and assisting in resolution. Providing guidance and training to other coordinators and new hires. Reviewing and updating all enrollments issues: COB/MSP, LEP attestation, application processing, LIS status, OOA, PCP issues, and others. Tracking enrollment and disenrollment trends and numbers for sales and marketing. Attending meetings with vendors and other departments to maintain open lines of communication and create opportunity to better internal processes for the plan. Utilize various medical software such as Facets, Marx, ERPT, MDS, NPPES, Acuity, SharePoint, DocStar, and more on the daily. Providing CMS protocol on issues to provide better understanding. Pulling, reviewing, and working CMS reports. Performing root cause analysis and determining process to correct.

• Claims Coordinator

  • Nov 2020 - Aug 2021

  Tracking ongoing issues and assisting in resolution. Attending meetings with vendors and other departments to maintain open lines of communication and create opportunity to better internal processes for the plan. Utilize various medical software such as Facets, Marx, MDS, NPPES, Acuity, SharePoint, DocStar, and more on the daily. Providing CMS protocol on issues to provide better understanding. Review claim issues related to pay grids, copays, timely filing, provider billing (under/over payment), denials, prior authorizations, billing codes, contract issues, COB issues, and working to correct them. Review incoming refunds and perform financial auditing to determine claims impacted and the potential for reissuance of check. Verifying claim/provider status as INN or OON and processing correctly. Review of Medicare updates and impact to claim processing. Working any ongoing issues and large-scale projects regarding claims.



QTC Medical

• Euless, Texas, United States

• Clinic Administrative Coordinator

  • Sep 2019 - Nov 2020

  Direct clinic initiatives when no active clinic director, active leadership role for 4-5 months with no director. Handle all provider schedules within the clinic, this normally included 5 PCP’s, 1 audiologist, 2 Psychologists, and 1 Neuro. Review applications for new providers and set up tours of the clinic and to explain what QTC was about. Guarantee that the clinic was flowing, keep track of clinic metrics, and number of claimants seen. Follow both company and VA standards of practice, upholding HIPAA to the fullest extent. Transcribing patient history so that provider can adequately view and see claimant in allotted time. Update 201’s (billing forms) for both company and VA to appropriately bill correct appointment type, labs, and x-rays. Isolating system issues in E-Process and APAS and working with IT to resolve. Handling all phone board operation for clinic, company wide correspondence, provider communication, and clinic ordering. Resolution of any pended issues in system and clearing system daily.



MultiPlan

• United States
• Hospitals and Health Care
• 700 & Above Employee

• QA Auditor II

  • Sep 2018 - Sep 2019

  Followed and implemented projects and was responsible for direct supervision Review and audit negotiators open claims, closed claims, and calls. Making sure that all state and national health laws were followed with emphasis on HIPAA. Providing feedback to negotiators when any issues were found within audit. Assisting with the training of new negotiators and what to expect from an audit standpoint. Created training material for new hires in areas of known issue. Transcribing call errors and writing error reports for training purposes. Review Medicare claims for proper handling. Providing reports of positive and negative trends, productivity, and ongoing trends to upper management.



NTSP Silverback LLC

• Fort Worth, Texas, United States

• Eligibility Analyst/Provider Analyst

  • Feb 2017 - Sep 2018

  Verified member coverage for both Humana and UHC products, update member plans, update member effective dates, update termination dates for members, create new member accounts, update provider information, update provider contracts, and process claims. Review and read provider contracts to validate. Review provider accounts to verify NPI/TIN, add providers to the system, update provider information, and add or delete contracts attached. Created the training material for new hires and assisted in the hiring process. Provided full training once team members were onboarded by HR. Isolate issues or trends in the system and work to correct them, if unable to provide data to upper management for further analysis. Communication with other teams regarding eligibility and provider issues and updates.



Exceptional Home Health/Wendy McKinley

• Fort Worth, Texas, United States

• Home Health Care Coordinator

  • Jun 2012 - Apr 2017

  Examined pended claims to identify key elements and processing Working directly with family to provide full in-home care through the Medicaid SSI program to special needs children. Providing all billing documentation to family for sign off on. Creating a plan of care for child with family and the rest of the healthcare team to follow on a daily/weekly basis. Outlining goals for the child to meet and working with child to achieve. Providing guidance to family on insurance and assistance programs that are provided. Completing all paperwork and submitting it back to office for processing.



Oncall RX

• Arlington, Texas, United States

• Pharmacy Technician/CSR

  • Sep 2015 - Sep 2016

  Operated as both CSR and Pharmacy tech in training. Under the supervision of Pharmacist operated in an after-hours pharmacy. Handled inbound calls from across the country of medical facilities and staff seeking medications for patients immediately. High paced call volume in which patient data, patient location, medication and dosage information, insurance information, and next dose time was all collected. Utilizing pharmacy systems to see if there is a current, valid script on file or not. Valid scripts resulted in calling local pharmacies to urgently fill the medication, sending script, and scheduling courier for pick up and delivery. If no script was located on file for member, we would call the on-call doctor for pharmacist to take a verbal, locate a pharmacy with medication, send script, and schedule delivery. Documenting issues encountered with pharmacies and potential fixes. Making sure to accurately bill facilities and contracted pharmacies for services rendered.



Plaza Medical Centers

• United States
• Hospitals and Health Care
• 1 - 100 Employee

• Certified Nursing Assistant

  • Mar 2014 - Mar 2015

  CNA and unit secretary primarily for the Bariatric, Med-Surg, Cardiac/Neuro floors of the hospital. Manage 15-30 patient bed units at a time. Assisting nurses and doctors with patient care such as checking vitals, personal hygiene, check blood sugars, assist with ambulation, bathroom needs, measure input/output, chart all updates and data in patient charts, speak and update patients and family, get patients ready for procedures and surgery, and provide urgent data to nurses and doctors. Transcription for residents and doctors reviewing medical charts. Handling phone board and paging for the floor. Radioing needs to nurses across the floor. Managing floor desk for all patient charts, patient moves, transportation, in flow of patients, and visitors.



Victory Medical Center Mid-Cities

• Hurst, Texas, United States

• Admissions Specialist

  • Mar 2013 - Mar 2014

  Working as the front desk of the surgical center. Verifying insurance coverage, working with insurance to get prior authorization, determining deductibles and copayments with insurance. Working with patients to explain INN vs OON benefits, elective procedures vs necessary covered procedures, explaining costs, and hospital policies. Making sure that medical record charts are created prior to member arriving, making sure all ICD-9 codes were correct for member, diagnosis codes were valid, payments were secured prior to surgery, claimants added into system with authorization(s) attached, all consents gone over and signed with claimant, and labels ready. Doing the admissions process for anyone who came in through the ER as a STAT admit. Maintaining phone board and paging system hospital wide, corporate email communication, notarizing documents, handling hospital mail, verifying shipments and deliveries, managing meetings for upper management, keeping lobby clean, checking in vendors and assisting them to specific areas, and providing families with updates.