Oversee enterprise call center operations to ensure efficient workflows and processes are deployed to ensure a high standard of service. Monitor and report on call center operations and metrics to business unit leaders and executives to ensure success. Facilitate analysis and implementation of tools and solutions to further enhance the call center experience and support an omnichannel approach to communications.Plans, directs and organizes call center functions across the enterprise, including mail handling, ticket management.Participates in capacity planning /workforce management exercises with business unit leaders to ensure success of solutions delivered.Lead call center QA process to drive quality of services.Ensures redundancy/failover processes are in place and functioning as expected.Develops team of subject matter experts to support operations.Train new team members on call center functionality to ensure success.Provide call center performance reporting to executive team and business unit leaders.Suggests operational improvements based on analysis of call center operations.Ensure ongoing compliance with all call center regulatory requirements. Provides active response and resolution to escalated issues within each business unit.Assessment, extension, and integration of call center operations to new acquisitions.Ongoing evaluation of administrative workflows to drive optimization.

Quality/Operations Manager for URAC accredited Care management corporation with primary focus on self-funded, self-insured market either through direct contracts or Third-Party Administrator (TPA) relationships. Manage Care case letter program for accuracy/state requirements. Knowledge and correct application of URAC standards, principles, and procedures. Implement new and updates to internal Policies and Procedures. Maintain Summary Plan Documents and other related resources relating to service requests from clients. Review and resolve complaints/grievances. Implement and update the disaster plan. Develop Quality Improvement projects regarding consumer safety and access to services. Management of office equipment, telephones. Provide oversight of all timecards/PTO requests for the entire Care department of 40 employees. Create and update all training materials. Provide initial system/process training to all new Care employees. Provide administrative oversight of all clerical aspects of the Care Management Department. Data collection and evaluation of data as it applies to productivity/phone stats and reporting for the care department. Provide oversight of all mailings, data entry, and care phone systems. Knowledge of all workflows including CM, DM, UM, QA Complaints/grievances, Disaster Recovery, consumer, and employee safety. Supervision of all non-clinical Care support staff. Provide support for Physician Advisor/Medical Director. Verify and assist with credentialing and re-credentialing of Nurses and Physicians. Understanding of Self-Funded/Insurance industry, along with CM/DM/UM/QA industry standards. Provide support to the accounting department as needed for invoicing. Provide assistance with case assignments to nurses. Ability to work collaboratively with clinical staff. Responsible for providing all aspects of excellent internal and external customer service and development.

Answer live calls in a queue. Initiate the precertification process if determined to be applicable. Manually reconcile all Physician Advisor invoices. Responsible for eligibility and loading patient as needed. Record and maintain main greeting that customers hear when they call. Follow up on “Tickle” list daily to make sure it stays up to date. Return voice mail messages as needed. Maintain retro log for Utilization Nurses. Support person for Utilization Nurses. Compile quality data for quarterly meetings. Accomplishments: Reorganized the Utilization Department to a paperless process. Restructured administrative process to be less repetitive and more productive.  Developed a better working knowledge of the Utilization process and medical terminology.

Resolution of Quality of Service/Quality of Care Complaints. Facilitate the resolution of Utilization Management Appeals with Quality Clinical Coordinator. Responsible for tracking and trending of all complaints and appeals. Prepare quarterly reports for presentation to the Quality Over-Site Committee. Built an Access database to track all complaints and appeals for ease in tracking and accurate information. Responsible for sending out Utilization Management customer surveys, Case/Disease Management customer surveys and compiling CM/DM survey reports quarterly for Quality Committee. Assist with tracking of Stage Licenses renewal dates. Assist with preparation for URAC desktop and on-site reviews. Maintain ongoing tracing of all Care Management training programs and individual staff members attendance to training programs. Back up for CM/DM Case Report Coordinator. Created and managed QOC meeting calendar to ensure all policies and procedures were reviewed and approved annually. Ensured that all licensed staff is meeting credentialing requirements through timely license verification. Scheduled continuing education lunch and learns for nursing staff. Accomplishments: Successfully accomplished two URAC accreditations with no errors while working with the Quality Manager. Created a tracking process for Complaints and Appeals in an Access Database. Created new and improved tracking for continuing education for all nurses internally and externally.  Developed a better work knowledge of URAC standards. Developed tracking tool for State licenses. Successfully completed course training in HIPPA guidelines.

Provide customer service to providers, members, hospitals and 50 Third Party Administrators. Generate bi-weekly reports in Microsoft Access format to update Third Party Administrators for Group Health and Workers’ Compensation products. Processed all special reports and projected requested by the Director of Managed Care. Perform audits on claims for application of the appropriate fee schedules and hospital rates. Coordinate with the TPA in the reprocessing of a claim when necessary. Provide fee schedule to physician’s offices according to the group and physician contracts. Coordinate the workflow and time management with three employees. Accomplishments: Develop a better working knowledge of how a PPO network is structured.  Self-taught the Access database, Excel, Lotus 1-2-3 and Microsoft Word.  Designed, developed, and implemented the Ancillary information for the provider directory.

Analyzed medical claims for payment. Verified validity of claims and approved payments to providers for services rendered based on appropriate plan document. Accomplishments: Consistently exceeded goals of claims process with excellent quality. Completed Managed Care courses.  Successfully completed training in microfilming.