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Yyyyyy x. yyyyyy
0000 xxxxxx xxxx , xxxx , xxxxx 00000 914-235-7108 abc@xyz.com
Healthcare Industry Manager
Dynamic, hardworking and responsible professional with over 13 years of progressive managerial and supervisory experience. Skilled leader as it relates to developing and managing top-tier teams that deliver superb service and drive goal achievement. Take on a leadership role in driving staff teams towards success, as well as in heading special project efforts. Liaise cross-functionally to fuel levels of enthusiasm, partnership and throughput. Capable of effectively assessing and measuring the efficacy of company programs. Adept in client needs assessment using a consultative approach to customer service delivery. Proven aptitude for overseeing multiple projects at once, including planning duties. Effectively manage both operations and administrative daily functions. In pursuit of a Supervisory Program Specialist (Practice Manager) role in a setting that will allow for continued growth and development, as well as a focus on the healthcare industry.
Core Skills
Supervision | Personnel Relations | Staffing Functions (Hiring) | Training | Support Delivery | Workflow Planning
Performance Assessment & Recognition | Quality Assurance | Interviewing| Communication | Program Support
Project Management Strategic Planning | Leadership | Insurance Knowledge | Activity Tracking | Healthcare Acumen
Efficiency Measures | Human Resources |
Records Management | Financial & Budget Functions | Management Principles
Process Improvement | Conflict Resolution | Problem Solving | Organization | Time
Management | Prioritization
Technology
Windows | MS Office | Adobe Illustrator, Photoshop | Novel | CorelWordPerfect2000 | AS400 | SPSS
Teradata | Business Objects | Web-based & Contract Application | SharePoint | Raiser s Edge | Centricity
Pathway LIS | WinSurge | One Base | EasyPrint | Medwatch | Mainframe | IDF | eSD | FRP | MS | Cognos
Emptoris | CCI Navigator | Raiser s Edge Citirx | Citrix | Facets
Career History
OrthoNet | Manager, Policy Administration 2016-Present
Oversee workflows for a team of Policy Administration Analysts in offering support while developing and implementing strategies to lunch policies across a utilization management musculoskeletal benefit management company
Administer Utilization Management (UM) approval, partial denial and denial templates, as well as state-required enclosures including ones that explain member appeal and grievance rights
Create links between areas; supervise the Policy Analyst within the Policy Administration department to manage their daily workload
Ensure efficient facilitation of UM templates to internal medical management departments in alignment with regulatory timeframes to deliver coverage determinations to members and providers in adherence to URAC and NCQA protocol
Drive the development of all delegated program correspondence for health insurance clients throughout the country in the commercial, Medicare and Medicaid market sectors
Streamline policy administration, governing matters and work plan development across areas of expertise; also lead budgetary measures to support to health plan clients cross-functionally
Research policy administration to deliver background briefings and data to council members, management and external organizations
Analyze and reply to OrthoNet Audit and CAP; hold consultations to make complex policy decisions and offer advice from an outside standpoint
Research and author and documents for consultation, vendor delegation, policies/standards and guidance
Also author briefings, reports, consultation forms, committee papers and web/intranet content with attention to detail
Liaise with staff to manage policy functions, as well as promote OrthoNet at conferences, meetings and events
Foster positive relations with essential stakeholders using cross-functional liaising with the communications division
Yyyyyy x. yyyyyy
Continued
FIDELIS CARE | Project Manager, Quality Management 2014-2016
Oversaw a project management budget of $3M that spanned over a three-year timeframe
Directed a team of over 30 across seven departments; led training and project supervision efforts
Drove key teams to aid business units in meshing quality measures into strategic and operational Key Performance Indictor (KPI) plans
Devised policies that influenced business tactics and ensured quality across departments
Developed and set forth programs with the Director of Clinical Services and Case Manager for programs including Chronic Care Improvement, Quality Improvements, Model of Care, MLTC, incentive programs and Structure & Process
Liaised with Informatics, Quality Management, Utilization Management, Clinical/Member Services, Provider Relations, Human Resources and Compliance to execute the aforementioned initiatives
Influenced decisions regarding design, development and strategy for departmental quality improvement projects for the National Committee for Quality Assurance (NCQA) and Utilization Review Accreditation Commission (URAC)
UNITED HEALTHCARE| Project Manager/Network Contractor 2009-2013
Led daily functions for a four-person team; also trained and supervised contractors contract submission
Audited contracts, claims reports and group rosters as needed
Tenaciously negotiated contracts and led multipart projects to support KPIs for hospitals, ancillaries and physicians regarding proper reimbursement, data collection and key process controls
Fueled the achievement of strategic goals specific to department training and accreditation endeavors
Actively played a role in supporting the provider database development
Forecasted monthly and annual contracts and financial objectives; also assembled reports for internal and external parties to forecast retention, trends and revenue in the market region
Directed contract submission efforts to make certain that rules and regulations were adhered to
Performed quality assurance reviews to guarantee that accounts were properly completed
Monitored staff productivity and suggested process improvements as needed
Identified issues and used research data to suggest revising standard operating procedures (SOPs) and contract submission processes to executives
Calculated a fee schedule for remediation projects that drove continued compliance within the market region
Researched claims to determine accuracy, CPT coding, HCPC coding and root causes for addressed issues
Developed a comprehensive provider database that reduced renewal and yearly missed contract increases by 100%
Additional Experience
Auditor, Medco Healthcare Solution, 2006-2008
Lead Regional Account Manager, AIM Healthcare Service, 2003-2006
Business Manager of Bursar/Registrar, Mercy College, 2000-2003
Education & Credentials
Master of Public Administration, Public Service, Seton Hall University, 2014
Bachelor of Science, Health Service Management, Mercy College
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