• Conducts comprehensive provider network examinations of health insurers and pharmacy benefit managers (PBMs).• Creates reporting templates and workflows to ensure regulated entities comply with laws and regulations.• Conducts market analyses to interpret data and financial information; drafts reports summarizing findings/conclusions and communicates results to senior management.• Manages long-term regulatory projects, requiring continued coordination with other departments, including in-house legal counsel, and regulated entities.

• Investigated and analyzed consumer complaints to ensure insurers complied with applicable laws and regulations and their contracts of insurance. • Mediated resolution of disputed claims on behalf of consumers. • Drafted correspondence to inform consumers of decisions and any opportunities for appeal.Researched insurance laws and regulations, case law, and common business practices to identify appropriate requirements and remedies. • Determined whether there was sufficient evidence to refer complaints to the Legal Department for enforcement action.• Educated consumers about their rights through individual engagement and public outreach.

• Developed, managed, and implemented clinical projects, strategic plans, policies, procedures, and systems. • Responsible for fiscal management and supervision of administrative staff.

• Managed a team of 10 employees to ensure timely and accurate billing of insurance claims for the medical group and the posting of several million in monthly payments for the entire health system.• Analyzed business operations and implemented process improvements through project management.• Coordinated and collaborated with senior leaders in all departments to resolve billing issues.• Regularly prepared and presented presentations to senior leaders including the CFO.

• Managed a team of 5 employees to ensure timely and accurate billing of clinic charges for professional claims for the entire medical group.• Resolved problematic claims to reduce accounts receivable days and coordinated with the coding team to systematically resolve claim edits and improve workflows.

• Provided customer service to patients via phone and in person regarding bad debt accounts; processed financial assistance applications; acted as team leader for the customer service representatives

• Primarily billed Blue Cross Blue Shield and Commercial Insurance claims; ensured the timely filing and accurate processing of insurance claims; resolved complex claims via appeals and troubleshooting.

• Sold, solicited, and negotiated auto and homeowner’s insurance policies; serviced existing policies.