Audited claims platform configuration facilitated by TPA to ensure appropriate benefit configuration.Reviewed and revised plan documents to ensure alignment with plan intent and to ensure appropriate benefit configuration.Oversight of TPA performance (Quality and Productivity) and trend analysis.Developed and Implemented Policies & Procedures and Desk Level Procedures specific to ERISA product Claim Handling.Developed and Implemented Polices and Procedures as well as Desk Level Procedures specific to ERISA product Appeals, Grievances and Provider Disputes.

Translated business requirements into viable solutions specific to system configuration.Collaborated with various vendors on the development of internal processes to ensure seamless transition to new systems post-go live. Created Policies & Procedures specific to NCQA accreditation.Built productive working relationships and collaborated across organization to meet project needs.

Collaborated on the development of fundamental operational functions for start up health plan.Claim Operations: including Third Party Administrator benefit configuration implementation, inventory management, claim batch audits, and check runs.Drafted plan documents for execution.Developed and Implemented Policies & Procedures as well as Desk Level Procedures specific to Claims Handling as well as Appeals & Grievances.

Designed and implemented robust Enrollment, Eligibility, Underwriting, Claims, and Appeals & Grievances operations for start up individual commercial health plan. Led Claim Operations: including annual Third Party Administrator benefit configuration implementation, inventory management, oversight (Quality and Productivity) and Trend Analysis.Evaluate plan documents for operationalization requirements ahead of state filings and oversee revisions to address Division of Insurance (DOI) objections. Developed and Implemented Policies & Procedures as well as Desk Level Procedures specific to Enrollment/Eligibility, Underwriting, Claims Handling as well as Appeals & Grievances.Collaborate with risk adjustment team on data validity and cleanup for Edge server submission. Developed and Implemented Quality and Productivity programs for both Enrollment & Eligibility and Appeals & Grievances staff.Prepare regulatory reporting and documentation for Utilization Review Accreditation Commission (URAC) and Healthcare Effectiveness Data and Information (HEDIS) audits.

Created Policies & Procedures specific to the management of claims to ensure compliance with state and federal regulations.Tracked, researched, resolved and responded to regulatory complaints in accordance with state specific regulation.Oversight of Third Party Administrator handling Enrollment, Premium Billing, Claims Adjudication and customer Service.Produced regulatory compliance reporting.Facilitated closure of the health plan by managing claims run out.