Post career, and previously hired as Manager, Audit Management at WellMed Medical Management, Inc. prior to UnitedHealth Group (United Healthcare / Optum Rx) who owns 75% of WellMed Medical Management, Inc. Position at United Group/Optum Rx was Supervisor.Increased Sr. Clinical Quality Analysts Prior Authorization Audit Reviews and Disputes (Rebuttals) to 95% and higher

Quality Control (QC) Compliance ManagerDirected auditing quality control (QC) compliance reviews of CaptureRx technical systems created for operations implementation team, quality compliance reviews and process improvements of 340B Program.Managed and trained three (3) direct reports, assisted auditing patient/provider encounter files, Pharmacy Benefit Manager (PBM) systems and investigated data for fraud activities.Developed and simplified team policies and procedures with HR programs resulting in process improvements, which increased processing time by 20%.Collaborated with project managers and developed scheduling models for software development, reports for workflow implementation, compliance, operations, customer service, claims and pharmacy validation, within budget and reduced errors by 30%.Completed user acceptance testing (UAT) on system enhancements and documented feedback, systems issues in database for software development team.

Managed quality assurance (QA) quality control (QC) and compliance team auditing operational process of Medicare Advantage (MA) and Medicare Advantage-Prescription Drug (MAPD) plans, to the Centers for Medicare & Medicaid Services (CMS).Managed coached, trained 11 direct reports; simplified and improved team policies and procedures to ensure audit review guidelines followed state, federal, compliance regulatory requirements; validated departmental adherence to HR programs, Standard Operating Procedures (SOP) and Statement of Work (SOW).Developed and implemented process improvement program within in 90 days to motivate and inspire department consisting of 30 plus employees that increased production and quality goals, from less than 94% to 99%.Collaborated with compliance officers completed and facilitated audits for CMS Quality Improvement Project (QIP), code of conduct, appeals, complaints and grievances for State Department of Insurance, OIG Compliance Plan, Special Needs Plans (SNPs), Presented external SOX-Audit, Model Audit Rule (MAR), HEDIS data for NCQA accreditation process, and ad-hoc reports for executive management,Collaborated with IT and BAs to develop new quality control test enrollment automation platforms system; completed user acceptance testing (UAT); approved software application acceptance for release to production, resulting in reducing 30% manual processes audit reviews.Cross-trained staff to assist member/customer service workflow, audit beneficiary, client/customer and provider calls, within 24 to 48 hours.Managed vendor relations for hiring over 20 temporary employees during Medicare Annual Enrollment Period (AEP); created new employee 90 day on-boarding plans and team job aids.Analyzed directives, reports, data records to develop dashboard to incorporate error root cause analysis, error descriptions, trending and tracking graphs of departmental performance into Excel, SharePoint. Reported daily in executive leadership meetings

Project Leader | Provider Services Supervisor at Texas Medicaid & Healthcare Partnership (TMHP) Managed and led diverse cross-functional TMHP provider relations department consisting of 30 plus employees who successfully recruited/retained network providers, resolved claim issues, account receivables and provided medical support for traditional Medicaid and various Medicaid managed care programs, including STAR, STAR+PLUS, LTSS, CSHCN, Transportation Program, Texas Women’s Health Program, CHIP, and Temporary Assistance for Needy Families (TANF). Collaborated with Texas Human Health Services Commissions (HHSC), Frew Advisory Committee, TMHP executive management and state stakeholders on Medicaid regulatory changes and projects, and worked with BAs to develop monthly Medicaid executive management reports.Managed HR functions including Key Performance Indicators (KPI) reviews and metrics to motivate staff, setting goals and objectives, to consistently surpass 95% contract/program service level agreements (SLAs).Customer Care Supervisor | Provider Enrollment Supervisor at Wisconsin Physicians Services (WPS)Led change management activities and process improvements, start-up and closing operations with WPS/Xerox to establish corporate policies and procedures, attainable goals and challenging objectives for 84 employeesTracked office expenditures, developed team workflow improvement processes and procedures, and managed, trained and coached 15 direct reports who exceeded 95% production and quality goals, following organization values, state, federal laws and regulations, compliance regulations.Streamlined business processes by developing and implementing process and performance improvements within budget constraints to reduce costs by 30%, and completed team annual budget and financial reports for performance directorAddressed and resolved escalated provider/client/customer complaints, within 24 to 48 hours.

Provider Outreach Education CoordinatorDeveloped and facilitated training programs and curriculum mandated by CMS, to protect the Medicare trust fund.Reduced provider inquiries, claims submission errors 30%, by educating network providers throughout the United States about Medicare fundamental programs and regulations, systems, appeals, grievances, policy changes, Fraud Waste and Abuse, Coordination of Benefits (COB), Medicare Secondary Payer (MSP), and HIPAA regulations. Interacted with departments within the organization for problem resolution; analyzed and effectively resolved escalated provider/customer issues and enrollment issues to assist operations, customer service, claims, compliance, billing, pharmacy and credentialing departments, within 24 to 48 hours.Received 4.6 out of 5 point average evaluation scores for classroom training, teleconferences, web-based training sessions, and performed training needs analysis from surveys, questionnaires and evaluations to develop ongoing training, meeting company vision, and CMS compliance goals and regulatory requirements.

Financial Services, Fixed and Variable AnnuitiesSupervised and led two (2) week new employee orientation for 54 employees and facilitated comprehensive training programs for contact center, sales, customer relations, licensing and operations teams.Launched new training delivery methods for non-exempt/exempt staff; developed and simplified job training aids for new employees and training projects/needs assessment within time and budget constraints for project managers that resulted in reducing training cost per hire by 45%.Designed and created effective and efficient policies and procedures for 23 licensing department employees resulting in timely payments for brokers/agents.

Group and Individual Voluntary BenefitsFacilitated and led three-day seminar educating brokers, agents, and field sales personnel on group voluntary life insurance benefits, cafeteria plans and group universal life (GUL) insurance. Prepared competitive analyses, RFPs, and identified areas for GUL market growth.Facilitated classroom training on voluntary life insurance products individual and group medical underwriting and billing.Assisted implementing cross-training protocols that significantly increased new employee production.levels.