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Yyyyyy x. yyyyyy

0000 xxxxxx xxxx , xxxx , xxxxx 00000 xxx-xxx-xxxx |


Profile of Qualifications


  • Results-oriented Professional possessing excellent leadership, quality assurance and organizational abilities.
  • In-depth knowledge of Medicare Part B and Part D.
  • Regarded for ability to spearhead existing processes and implement successful strategies to increase efficiency throughout day to day operations.
  • Top notch interpersonal skills, key to forming positive relationships with third parties and team members.


Key Areas of Expertise



  Quality Control

  GHI Market Prominence & Mainframe

  Process Improvement

   Regulatory Compliance

   QCare, OMT & eRPT

  Interpersonal Communication

  Training & Development

  MS Office Suite


Professional Synopsis


Cognizant Technology Solutions (Formerly Emblem Health) 2009-2016

Quality & Compliance Specialist

  • Utilized in depth knowledge of Medicare Part D, coupled with strong organizational skills and attention to detail, to perform assigned tasks on time in a fast-paced environment.
  • Ensured compliance to all policies, internal controls and SOX regulations.
  • Responsibilities included conducting in depth data analysis, maintaining quality control and case management.
  • Thoroughly verified files updated in GHI Mainframe, GHI Market Prominence, Softheon and QCare.


Emblem Health (Formerly Group Health Incorporated) 2002-2008

Provider Enrollment Manager

  • Fulfilled key leadership position, overseeing daily operations within enrollment department.
  • Leveraged strong organizational skills to oversee preparation, credentialing, processing and maintenance of healthcare providers for enrollment in Medicare Part B.
  • Streamlined existing processes by contributing to creation of internal tracking system; identified inefficiencies and developed effective strategies to increase performance.
  • Developed and implemented successful training initiatives to increase employee performance and provide updates in regard to policies.
  • Demonstrated excellent communication skills throughout provider interactions and inquiry resolution.
  • Ensured adherence to all policies and regulations, critical to maintaining eligibility.
  • Effectively communicated all changes or updates to staff to ensure critical compliance with standards; included efficiently updating internal control documents.


Group Health Incorporated 1997-2002

Benefit Integrity Manager

  • Oversaw daily operations, with associated duties including maintaining quality control and participating in discussions with CMS, OIG, FBI and other Medicare contractors.
  • Developed and implemented effective training initiatives for staff members; presented information regarding Medicare Part B in multiple seminars.
  • Properly handled fraud complaints; conducted investigations, data analysis and testimonies as necessary.


Education & Professional Development


Computers in Business Continuing Education, York College

High School Diploma, Springfield Gardens High School,

CMS Provider Enrollment and OIG Presentation Training

CMS Investigative and Data Analysis Training

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