Karen Moncada Email & Phone Number

United States

Miami, Florida

Coral Gables, Florida

• Lead and collaborated with our BPO (Cognizant/Trizetto) during plan’s start up in 2011. Tasked with establishing our enterprise systems and accomplished a Fall 2012 Go Live for CMS’s AEP.• Developed, configured and validated key functions in the enterprise system as they related to our Enrollment Department. Using EAM and QNXT, our enrollment, benefits, time-sensitive correspondence mailings, provider membership records, and call tracking functions were all built into and managed in these systems to improve our daily operations critical for claims adjudication, benefit utilization, sales commissions and network provider capitation payments. Maintained improvements through change pack updates and continued validation.• Expert in defining and analyzing goals and requirements through analysis and interpretation of business reports using our database and creating decision-making tools for operational queries sought by executives and chief officers.• Monitored and advised on performance metrics through internal audits of our processes to ensure adherence to SOPs and regulatory requirements of contract with Centers for Medicare and Medicaid (CMS). • Created, maintained and reviewed local and system data files of enrollment transactions and premium services for use in reconciling data and payments between the health plan and CMS. In addition, directed staff in the review, processing and submission of enrollment transactions to ensure completeness, timeliness and adherence to CMS regulatory requirements.• Developed and updated policies and procedures, screened, hired, terminated and evaluated staff. As well as, created training materials and trained various staff on enrollment processes, regulatory government guidance and best practices, and for new or special projects as needed.• Lead department audits for CMS, state of Florida and third party independent auditors during external audits and investigations of the plan to monitor and report on regulatory adherence.

South Miami, Florida

• Collaborated with case managers, psychiatrist, physicians and counselors to maintain member’s compliance with treatment regimens.• Performed weekly clinical record audits to investigate departmental adherence to company, state and federal standards.• Inspected, prompted and assisted members with managing medication regimens and symptoms when demonstrating exacerbated symptoms or difficulties with managing treatment regimen independently. • Evaluated, developed and trained members in basic life skills, such as activities of daily living, home maintenance, and conflict resolution to promote self-reliance, improve independence and involvement in achieving recovery and maintain social functioning. • Facilitated member’s linkage to community resources for access to information, education services, legal aid, nutrition seminars and other services as needed.• Coordinated meetings with members and their corresponding service staff to outline concerns and implement binding contracts to resolve concerns and disagreements.• Managed and maintained all assessment data, progress and billable notes in software applications in compliance with reporting requirements as defined by the organization, department manager, state and federal requirements.

Doral, Florida

• Supervised, coordinated and troubleshot daily front end operations and problems to ensure staff productivity, adherence to policies and procedures and smooth functioning during low and high volume hours.• Executed daily bookkeeping procedures; balanced and reconciled all staff, lottery and store cash drawers, managed bad check restitution, prepared wire transfers, money orders, and various tender bank deposits.• Provided superb customer service; resolved customer concerns and troubleshoot problems to ensure customer satisfaction.

Bachelor'S Of Science, Health Services Administration

Activities and Societies: Honor Society

Bachelor Of Arts, Psychology

Activities and Societies: Psi Chi Transferred / Switched Field of Study

Associates Of Arts, International Relations