Responsible for building trusted strategic relationships within an account.Requires identifying and assessing complex problems for area(s) of responsibility. Creates solutions in situations in which analysis requires in-depth knowledge of organizational objectives.Interaction is with senior management levels at a client and/or within Accenture, involving negotiating or influencing on significant matters.

Responsible for the performance and operations of the Medicaid Programs division of Presbyterian Health Plan. Accountable for ensuring regulatory and contractual compliance under the Centennial Care contract with the New Mexico Human Services Department (HSD). Provide oversight over the performance and operations of subcontractors delivering the array of covered Medicaid services to enrolled members. Serves as the primary point of contact for internal and external customers, HSD, the Collaborative, as appropriate, the Centers for Medicare and Medicaid Services (CMS), other state agencies, stakeholders and the public.

Responsible for organization, implementation, direction, strategic development, and daily operations for the Presbyterian Health Plan (PHP) Nurse Advice Line/Clinical Navigation. This position leads the planning, assigning, coordinating, implementing and evaluating all services within the call center, including staffing, has oversight of nursing triage and clinical care, information and telephony systems, and quality improvement activities. Implements Nurse Advice Line and telephone triage clinical protocols and assesses and implements request from providers for the need for coordination of services members whose care can be coordinated within the network. Develops and executes procedures to ensure that performance standards for quality, timeliness, and compliance are achieved. Aligns strategic goals and objectives across PHP clinical and operational areas, in concert with relevant stakeholders, to ensure defined solutions meet core business objectives.

Manages and oversees all activities associated with Mi Via Operations. Determines work priorities of Mi Via Operations team; has accountability for functions performed by staff. Selects, develops and assigns staff as needed to meet strategic and operations objectives. Provides active leadership and coaching for the Mi Via Operations Manager, Participant Liaisons and Project Specialist. Provides strategic direction for Mi Via Operations team.Manages and maintains excellent customer relations.Acts as communications point person for ACS with State of New Mexico for Mi ViaWorks cooperatively with all other areas of the account management team.Develops creative solutions to address complex issues for the account and customer.

Direct a staff of 53 employees to ensure excellence in customer service to health plan members and participating providers.Maintain and prepare the budget for Customer Care Center Operations.Ensure compliance with all Human Service Department performance and reporting requirements for the state of New Mexico.Ensure all performance measures and guarantees for quality accuracy and service are achieved to comply with NCQA, HEDIS, and health plan customer requirements.Chair and facilitate interdepartmental committees to ensure high quality cost effective service to health plan members. Facilitator for the Lean Kaizen process within the health plan 2010.Maintain ACD operating systems for the health plan to ensure compliance with regulatory reporting requirements.

Manage staff of 19 from Lovelace Medicaid, Lovelace Senior Plan, NM Retiree Health Care Authority, and Commercial Customer Care.Ensure department goals are met by monitoring performance statistics and reports for the department.Co-developed the training curriculum for an eight-week training program for the Customer Care Center and other health plan departments.Represent the Department at external meetings with purchasers, federal and state government and state providers.Implemented an Interactive Voice Response System (IVR) for the Department to improve services to customers.

Description: Supervise a staff of 10 Provider Response Unit representatives to perform multiple supervisory duties in order to ensure customer satisfaction.Maintain scheduling to workforce manage the department for providing adequate phone coverage to meet the departmental goals of a 30 second speed of answer and less than 5% caller abandonment rate.Conduct operational meetings with Provider Affairs Specialists in order to resolve participating provider claim issues.Facilitated meetings which resulted in streamlining correspondence workflow throughout the company.Implemented change in work hours for all customer service areas to maintain adequate phone coverage for an increase in satisfaction for health plan members and providers.Summarized and modified documentation for the pay-for-service program to improve the quality and auditing of phone calls in addition to modifying policy and procedure for the Customer Service and Provider Response Department during the Molina transition process.

Supervise a staff of seven including four Consumer Assistant Specialist and Hearings Coordinator and three support technicians.Direct the work assigned to the Program Integrity Staff.Ensure that all complaints, appeals, and grievances were resolved timely and accurately while adhering to all regulatory and contract standards.Assist the Manager in the hiring, promoting, and evaluations of staff. Provide education and training programs about the Complaint/Appeal and Grievance Processes to internal and external customers.Resolve all complaints and appeals accurately and timely consistent with the guidelines of the

Supervise staff of 12 claim processors for the commercial account and six processors for the QualMed account.Member of the Reconsideration Hearing Committee to review members' appeals and complaints. Member of the Quality Service Action Committee Complaint, Appeals and Grievances (QSAC CAG) sub-committee that discussed ways to reduce complaints and appeals.Claims Department expert to test new versions of the claims processing system.GBAS Training and Documentation Coordinator; Training and Documentation Specialist; Training

Coordinate and organize all claims processing system training for Health Care Horizons.Document and coordinate all desktop procedures for the uses of the claims processing system.Implemented the first company-wide call-tracking training program.Maintained documentation issues for the system conversion process.Created all claims system training manuals for company use.Audited, adjusted and researched claims to insure quality.

Trained new employees and temps to process claims.Processed claims for outside providers who used the Lovelace Health Plan.Audited, researched, and paid transplant claims.Reconciled check runs.