Experience

PPMSI

• Hospitals and Health Care
• 1 - 100 Employee

• Director, MSO Operations

  • Jun 2022 - Present

  Operational leader and Ethics & Compliance Officer, directing all MSO activities associated with Claims, Compliance, Credentialing, Customer Service, Provider Network Operations, and Quality Improvement. Ensures all departments are compliant with contractual, federal, state, and local regulatory requirements and identify areas of risk for CMS, DMHC, HEDIS, HIPAA and NCQA requirements to develop, implement, track, and report on work plans for corrections. Consults with other departments and Senior Management on issues for existing and planned operations. Partner with Information Technology for resolution of systematic programming issues Participate in development and implementation of necessary education programs to ensure staff is knowledgeable about compliance responsibilities on an ongoing basis. Develop training manual and update it as necessary.



Value Based Healthcare Partners

• United States
• Wellness and Fitness Services
• 1 - 100 Employee

• Director Of Operations

  • Jul 2020 - Aug 2021

  • Healthcare operation oversight of Enrollment, Claims, Provider and Call Center teams • Medicare Advantage Plan Implementation & Supplement Benefit Vendor Management (Offshore & Onshore) • Manage CMS Compliance, Appeals & Grievances, and Provider Network Relations and Credentialing strategies • Project management of configuration and DOFR contractual responsibilities (including SSA) • Create and maintain policies, procedures and workflows at 1 month upon hire • Design CMS Enrollment model letters, templates & standards, prepare readiness checklist and reporting • Ensured plans meet regulatory requirements prior to go-live on effective date



Aetna, a CVS Health Company

• United States
• Wellness and Fitness Services
• 700 & Above Employee

• Operations Manager

  • Aug 2018 - Jul 2020

  • Claims, Audit, Quality Review and Medical Review administrator of Individual & Medicare products • CMS/DOI Appeal & Grievance complaint response with RCA and CAP outlined • Collaborator with actuary, compliance, enrollment, legal, premium, and FW&A colleagues • Establish SLA & KPI performance goals • Partner support to Medicare team (claims and call center) • Build strong teams via training, coaching, mentoring and professional development • Develop team restructure pilot to improve cross functional processes; incorporated enterprise wide, next quarter • Expedite online process improvement library resource in partnership with matrixed teams • Monthly (+ad hoc) presentations to senior leaders and associates



WellCare Health Plans

• United States
• Insurance
• 700 & Above Employee

• Manager, Operations Call Center Audit

  • May 2017 - Jun 2018

  • Manage Medicare Advantage call center quality, audit and training • Improve communication with clear workflows to contact center leadership • Create performance metrics and standardized policies, procedures & reports • Develop SharePoint site to support call center operations and report detail access • Identify, create and maintain strategic and tactical initiatives based on trends • Audit & improve training manual for new hires and refresher training • Manage Medicare Advantage call center quality, audit and training • Improve communication with clear workflows to contact center leadership • Create performance metrics and standardized policies, procedures & reports • Develop SharePoint site to support call center operations and report detail access • Identify, create and maintain strategic and tactical initiatives based on trends • Audit & improve training manual for new hires and refresher training



CGI

• Canada
• IT Services and IT Consulting
• 700 & Above Employee

• Manager Healthcare BPO Consulting

  • Sep 2013 - Sep 2016

  • Manage ACA & Medicare client operations, call center, claims, benefit configuration, data analysis and reporting • Implement department procedures and policies to meet regulatory reporting standards • Create performance metrics and team training requirements • IT proprietary automobile insurance software project manager upon SOW execution • Manage ACA & Medicare client operations, call center, claims, benefit configuration, data analysis and reporting • Implement department procedures and policies to meet regulatory reporting standards • Create performance metrics and team training requirements • IT proprietary automobile insurance software project manager upon SOW execution



The Millennium Group

• Dallas/Fort Worth Area

• National Operations Manager

  • Apr 2010 - Sep 2013

  • Call center support consultant to Property & Casualty client • Oversee staff at 7 different sites to improve organizational proficiencies • Create staff training manual with system workflows, within first 30 days • Complete first external client audit at 98% result within first 2 months • Establish and enhance customer support to streamline processes, exceeding KPI targets • Call center support consultant to Property & Casualty client • Oversee staff at 7 different sites to improve organizational proficiencies • Create staff training manual with system workflows, within first 30 days • Complete first external client audit at 98% result within first 2 months • Establish and enhance customer support to streamline processes, exceeding KPI targets