Charles Smith Email & Phone Number

Houston, Tx, Us

• Provide leadership for health plan operational function areas including appeals and grievances, benefits, claims, enrollment, fulfillment, member services, provider services, security administration/application support, system configuration, and vendor management.• Oversee the performance of each functional area towards measurable goals, evaluating operational efficiencies with a focus on continuous quality improvement as well as compliance with business, contractual, and regulatory requirements.• Analyze operational trends and opportunities and provide updates and recommendations to executive leadership on health plan performance, strategies, progress, and issues.• Maintain up-to-date product and service knowledge to support internal teams, external vendors, health plan members, network providers, and other stakeholders.• Oversee and manage relations with all health plan delegates and vendors, including claims and benefits administrators, ensuring each maintains processes current and compliant with business, contractual, and regulatory requirements.• Oversee, develop, or manage special initiatives such as Centers for Medicare and Medicaid Services (CMS) annual call monitoring and data validation audits; the Medicare Advantage bid process; production of Annual Notices of Change (ANOCs), Explanations of Coverage (EOCs), annual member mailings, and health risk assessments; and system configuration of benefits.• Lead or participate on various committees as needed, including the Compliance Committee, Operations Committee, and Payment Integrity Committee.Achievements:• Coordinated investigation and remediation of irregularities in data extraction and reporting which had led the health plan to overstate its bid medical loss ratio (MLR) experience for several years.• Launched Merit-based Incentive Payment System (MIPS) adjustments to non-contracted provider claims.• Triaged successful business continuity response to Change Healthcare cyber security incident.

• Responsible for ensuring core operational function area policies, procedures, and processes reflected business, contractual, and regulatory requirements as well as the adherence to all such guidelines by both internal staff and external support vendors.• Developed opportunities to strengthen partnerships among core operational function area teams, other organizational departments, and external vendors supporting operational activities.• Provided guidance in the design and maintenance of the applications that supported core operational functions and initiated system solutions to enhance quality and create efficiencies.• Continually reviewed system capabilities to meet business needs, evaluate system integrity, and implement enhancements.• Devised strategies to ensure optimized performance of core operational function areas, identifying and implementing process improvements to maximize output and minimize costs.• Planned, monitored, and analyzed key metrics and underlying data for core operational function areas and external vendors supporting those activities to drive optimized accuracy, efficiency, and productivity as well as compliance with contractual and regulatory requirements.• Oversaw development and maintenance of library of management control reports for analysis of operational trends and to identify issues for implementation of corrective actions as needed.Achievements:• Shepherded Operations teams through successful reorganization, closure, and transition of business units, minimizing impact to employees, plan members, and network providers.• Implemented process for managing plan member Qualified Medicare Beneficiary (QMB) status.• Performed review of health plan encounter data submissions, identifying and helping remediate the lack of a process for working fallout encounters, thus boosting successful submissions.• Designed a tool for calculating adherence to Inflation Reduction Act (IRA) requirements and ensure Plan followed the guidance.

• Analyzed business processes and trends to identify and implement solutions for improving overall claims, contact center, and enrollment operations.• Managed tools and resources that supported oversight and monitoring of operations delegates.• Provided feedback and recommendations to leadership on delegate operations, performance, compliance, issues, and strategies.• Managed operational compliance with regulatory and contractual requirements.Achievements:• Designed delegate claims monitoring tool and implemented associated audit process.• Designed delegate contact center call monitoring tool and implemented associated audit process.• Implemented process for Operations and Compliance to track delegate operational issues.

Greenwich, Ct, Us

• Collaborated with executive leadership in the development of strategic organizational goals and long-term operational plans.• Devised strategies to ensure the growth of programs companywide, identifying and implementing process improvements to maximize output and minimize costs.• Developed, implemented, and monitored day-to-day operational systems and processes giving visibility into goals, barriers, and progress of company initiatives.• Planned, monitored, and analyzed key metrics and underlying data for Operations units to drive optimized accuracy, efficiency, and productivity.• Ensured compliance with all contractual and regulatory requirements.• Provided leadership to units responsible for appeals and grievances, authorizations, benefits, claims, client services, delegation oversight, eligibility, provider relations, and revenue cycle.Achievements:• Completed strategic assessment of all Operations units incorporating division structure, staffing, systems, and business processes to address identified deficiencies and position areas of responsibility for long-term scalability.• Led Provider Relations Team campaign to heighten engagement with network practices, address areas of provider concern, and drive increases in overall business volumes.• Coordinated Client Service task force to bring resolution of service requests from network practices from a 15-month backlog to response within same week of receipt.• Facilitated launch of offshore Operations team in Nepal inclusive of new hire training program.• Designed Operations quality assurance measurement tool for both onshore and offshore teams and implemented monitoring program inclusive of operating procedures.• Project lead of three cross-functional change management initiatives aimed at increasing provider network satisfaction, enhancements to the online provider portal, and claims leakage mitigation.

Pearland, Tx, Us

• Directed Claims Department which processed medical claims adjudication and payments, including other coverage investigations and coordination of benefits.• Oversaw claims overpayment recovery activities including receivables management.• Participated in delegate audits of commercial carriers as well as independent auditor reviews and rolled out corrective actions for identified issues.• Performed CMS claims data validation audits of organization determinations and reopenings and participated in annual plan HEDIS audits.• Managed processing Medicare Secondary Payer files to identify and submit discrepancies to CMS and health plan delegates in order to maximize revenue and contain costs.Achievements: • Restructured claims workflows to bring appeals processing turnaround times from 60% to 100% compliant.• Implemented processes to comply with federal mandates related to COVID-19 testing and treatment claims payment.• Translated all claims letters, notices, and explanations of benefits (EOB) templates into Spanish to comply with CMS guidance related to plan language accessibility.• Successfully launched process for claims bill reviews and recoveries with external vendor.• Contributed to early discussion sessions with IS teams implementing solution to CMS interoperability mandate.• Created tool for more precise calculation of member benefit period and lifetime reserve days inpatient stays.• Implemented process for tracking and reporting claims reopenings per CMS guidelines.• Operationalized compliance with CMS mandate to pay non-participating providers MIPS reimbursement adjustments.• Worked with IS and UM teams to identify possible leakage for observation claims billed as inpatient.• Participated in Mock CMS Program Audit and afterward addressed audit findings.• Identified claims recovery process irregularities that had led to $1.6M in unrecouped recoveries.

Pearland, Tx, Us

• Directed Enrollment Department which maintained member eligibility including demographics, disability status, low-income status, QMB status, and coverage effective dates; performed other coverage and out-of-area investigations; processed premium billing and associated accounts receivable; and fielded calls from members and providers regarding member coverage, eligibility, statuses, and premiums.• Performed CMS enrollment data validation audits and participated in annual plan HEDIS audits.• Led Quality Assurance team which audited Enrollment and Member Service units to measure accuracy, quality, operational effectiveness, and adherence to standard operating procedures as well as to identify areas of risk within health plan service operations.• Provided oversight of Training team activities including working with internal business partners to develop and maintain standard operating procedures, performance metrics, training goals, curriculum design, trainer and participant guides, activity guides, trainings, and assessments.Achievements: • Designed and operationalized tool for tracking health plan Sales Agent and Member Service Representative calls and responses to annual CMS call center monitoring audits in order to help maintain KelseyCare Advantage's 5-star Medicare Advantage rating.• Improved automation of tool designed to guide Member Service Representatives through plan change and disenrollment requests aligned with Medicare Managed Care Manual guidance.• Designed robust tool for auditing Member Service Representative call performance along multiple key measures related to service level and knowledge base.• Implemented Quality Assurance auditor calibration process to standardize audits.

Houston, Texas, Us

• Over delegation oversight audits of first tier, downstream, and related entities (from early 2016).• Led team that provided new hire orientations; product and business function in-services; curriculum design, call center trainings; and development and maintenance of company knowledge management system (from early 2016).• Headed team that monitored call center, claims, enrollment, fulfillment, appeals, and sales as well as data validation of Medicare Part C & D claims organization determinations and reopenings (from mid-2014).• Led Claims Department which handled medical claims adjudication and payments, coordination of benefits, overpayment recoveries, and subrogation.• Headed Customer Service Department which handled inquiries and complaints from members and providers, interpretation of benefits, initiating the appeals process, triage of claims issues, and participation in client benefit fairs.• Directed Eligibility Department which maintained member eligibility including demographics, COBRA coverage, dependent and disability status, tracking of pre-existing conditions, prior creditable coverage, and coverage effective dates as well as fielding calls regarding member coverage.• Over Fulfillment Department responsible for design, configuration, maintenance, and fulfillment of plan materials such as member ID cards, summaries of benefits and coverage, ANOCs, EOCs, EOBs, integrated denial notices (IDNs), and provider remittance advices.• Managed team responsible for configuration of plan medical benefits including interpretation of client plan provisions, maintenance of standard code sets, oversight of clinical editing software, and provider contracts.• Led Data Analytics team that created custom reports, data extracts and analyses, and contractual and regulatory filings (through early 2014).• Negotiated ancillary provider contracts and single-patient agreements (through 2011).

• Created quarterly and annual forecasts for various company lines of business.• Performed analyses of expense trends compared to budget including the utilization and financial performance of physicians as well as the impact of proposed contract changes.• Developed budget information at the specialty and regional levels.• Created custom reports for management and various external users.• Configured claims system code sets as well as professional and institutional fee schedules.• Configured system benefits including authorization and referral requirements, covered benefits, exclusions and limitations, and member cost share.• Tracked industry trends and laws applicable to the claims payment process.Achievements: • Participated in successful health plan URAC accreditation.• Designed health plan Integrity Program including drafting all policies and procedures and outlining the statistical data sampling processes dealing with the detection and deterrence of health plan employee, member, and provider fraud, waste, and abuse.

• Prepared all financial reports including monthly statements, annual budgets, pro forma financials for proposed lines of business, and various contract analyses. • Managed all company tax reporting including income, franchise, property, unemployment, payroll, W-2s, and 1099s. • Managed corporate accounts receivable and payable.• Configured system and managed process for physician claims payment and payer billing.• Managed clinical data capture process.• Maintained company malpractice, organizational liability, directors and officers (D&O), errors and omissions (E&O), workers’ compensation, and bonding insurance policies.• Oversaw employee health, dental, life, disability, and supplemental policies.• Oversaw employee pensions, payroll, benefits, and personnel records.Achievement: Participated on team responsible for developing and operationalizing a telephonic disease management program.

• Directed team that fulfilled data reporting requests from various external and internal users including the creation of ad hoc reports, data extracts, and data exchanges.• Directed team which loaded and maintained provider demographic and reimbursement information. This included reviewing professional and institutional contracts to verify correct system configuration and troubleshooting other provider capitation and claims payment issues.• Managed team responsible for the maintenance of member eligibility information, resolution of eligibility issues, and the monthly capitation reconciliation and payment process.• Managed team responsible for the configuration of member benefits.• Oversaw maintenance of system security profiles for NAMM employees.

• Maintained databases for multiple NAMM independent physician associations (IPAs).• Created custom reports including those required by federal and state laws for Medicare and Medicaid as well as other report requests from physicians, payers, and management.• Supervised team maintaining member eligibility information.• Generated monthly analyses of payer premiums.

• Maintained databases for multiple NAMM IPAs.• Supervised team maintaining member eligibility information.• Created custom reports.

• Maintained financial records, produced financial statements, and generated other reports such as capital lease asset schedules and expense trend analyses for two NAMM IPAs. • Calculated company surpluses, budgets, and physicians’ contributions to profitability.NAMM Achievements: • Successfully triaged business continuity event in which all claims system data from the prior 60 days was lost for all IPAs. Remediation included first rebuilding enrollment data by sequentially loading historical eligibility files and then utilizing archived data analytics reports to obtain key authorization, claims, and payment data in order to reconstruct lost authorizations and claims for import back into their respective databases.• Participated on a national team of multiple NAMM locations organized for a claims system conversion of authorizations, benefits, capitation, claims, eligibility, providers, and reporting.

• Performed all accounting functions for two AIM mutual funds.• Maintained all financial records including reconciliation of the general ledger.• Calculated the daily net asset values (NAVs) of each fund.• Performed monthly analysis of the funds’ expenses.• Prepared financial support schedules for the funds’ annual and semiannual reports.• Generated applicable state tax return documentation and regulatory compliance worksheets.• Generated other ad hoc reports for management.Achievement: Wrote coding to automate daily NAV calculations for multiple accountants’ funds.

Master'S Degree, Health/Health Care Administration/Management

Bachelor’S Degree, Accounting