• Accountable for the operational oversight and management of a multi-functional claims department.• Responsible for claims processing oversight for delegated providers.• Participate and attest all Part C CMS health plan reporting to include data validation activities.• Direct and participate in audits for Centers for Medicaid and Medicare Services (CMS) and Sarbonnes-Oxley.• Prepare and attest HEDIS audits for all Fresenius Health Partners CMS contract ID numbers.• Implement and configure new claims processing platform for new health plan go-live 1/1/2016.• Oversee Policy & Procedure creation, and team department adherence. • Accountable for budget adherence to G&A, created staffing models, and team training. • Co-creator and sponsor for employee engagement program, Cheers for Peers.• Review and approve encounter data submissions to CMS.

• Accountable for the operational oversight and management of a multi-functional claims department.• Managed four supervisors, several team leads and 60 associates• Responsible for claims processing average of 456,250 claims per month, with an average payout of $71 million dollars. • Execute contract requirements for the delegation functions of claims payment, and participate in delegation audits, for 6 health plans.• Direct and participate in audits for Centers for Medicaid and Medicare Services (CMS) and Sarbonnes-Oxley.• Prepare and attest HEDIS audits for all health plans.• Ensure that contract requirements for health plan reporting are met. • Oversee Policy & Procedure, and team department adherence. • Mapped out business processes and functionality for the implementation of new/updated software applications for operational efficiency.• Responsible for vendor outsourcing for data entry, including needs assessment, implementation, operational oversight and relationship management, contract compliance. • Directed Claims Customer Service Call Center Team which receives 15,000 monthly calls from providers, to resolve claims payment inquires. • Accountable for budget adherence to G&A, created staffing models, and team training.

• • Manage daily activities for a multi-payer claims department. • Ensure all claims are processed according to State and Federal regulation, guidelines and timelines. • Coordinate with insurance companies to do quarterly audits.• Act as a liaison between the claims department and internal and external auditors.• Accountable for department adherence of policy and procedure as it relates to regulatory, legal and HIPAA requirements.• Participated in an interdepartmental team of subject matter experts in preparation for URAC accreditation.• Recipient of the STAR Award for outstanding effort in URAC Accreditation • Recipient of the Presidents contribution award for Health Plan accreditation.• Primary role in the selection, business requirements design and implementation for a claims and authorization adjudication engine, (IKA).• Critical role in Citrus Health Care Florida divestiture and transition of claims processing functions to Texas operations.

• Provide direct oversight of the claims processing team.• Compile and track all production for the claims processing team for review by the claims manager. • Oversee training and hiring of all new claims processors.

• Responsible as the team lead for the claims examiner team for various markets. • Trained all new claims examiners• Maintained and updated all reference materials for claims examiners.• Oversaw daily production goals.

• Responsible to data enter and process over 200 claims per day.• Maintained the highest quality levels of the claims processing team.

• Maintained over 6,000 accounts.• Data entered daily charges and payments. • Posted all insurance and patient payments.• Created templates for all insurance forms and mailed.• Worked with all correspondence from insurance companies.

• Entered provider charges and patient payments from superbills for 20 physicians in the San Antonio area.• Created and edited insurance claims filed daily to several different commercial health plans, and to Medicare and Medicaid.• Made collection calls on delinquent patient accounts.

• Served a four year term.• Honorably discharged. • Highest rank achieved was E-4 Specialist. • More information can be provided upon request.