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0000 xxxxxx xxxx , xxxx , xxxxx 00000 ● 314-255-5166 ● abc@xyz.com

Claims Operations ~ Claims Configuration ~ Change Management

Staff Leadership ~ Continuous Improvement ~ Project Coordination

         Solid managerial skills including training, mentoring, performance management, and motivation to optimize morale and retention of top talent.

         Well-versed in design, coding, testing, and implementation of changes and enhancements within claims payment system.

         Able to efficiently process and navigate new configuration requests and changes to improve operations.

         Adept at needs analysis, KPI metrics tracking and reporting, records management, and project coordination.

         Exhibit dynamic communication skills toward effectively liaising between management and internal/external stakeholders in support of achieving corporate objectives.

         Consummate strengths in analyzing existing practices and driving process improvements to elevate customer service and satisfaction.

         Practical problem solver with an excellent blend of business, financial, and technical acumen.

         Highly skilled at connecting with and managing people from diverse cultures and backgrounds.

         Excel at steering projects and initiatives to maximize use of resources, boost productivity, control costs, and achieve performance benchmarks.

Centene Corporation, 2011 to Present

Business Analyst IV, Contract Implementation, Marketplace, Claims Operations (2015 to Present)

         Accurately interpret contracts for Marketplace line of business (LOB) to devise claim payment configuration for ancillary and national providers.

         Support and guide peers in department operations as SME for health plans related to Marketplace claims.

         Research and pinpoint root cause for claim payment issues pertaining to pricing and benefit configuration.

         Explore strategies to strengthen KPIs for Marketplace LOB and join forces with internal business partners to reduce pending claim volume.

Manager of Claims, Claims Operations (2014 to 2015)

         Spearheaded full-scope department operations serving Medicaid-contracted states by ensuring processing adhered to defined guidelines, compliance requirements, and KPI targets.

         Recruited staff for claims center as needed and functioned as SME to team members.

         Actively participated in planning and development of annual departmental budget.

Senior Operations Analyst, Network Development (2013 to 2014)

         Advised and guided external and internal customers in contract implementation for corporate national contracting activities.

         Investigated state manuals to ensure accurate payment of health care claims, reviewed payment methodology for contracts, and methodically conducted user acceptance testing (UAT) for contract configuration.

         Diplomatically liaised between national providers and internal departments to resolve provider and claims payment issues.

         Held meetings enterprise-wide to establish best practices for national contracting, and proactively orchestrated claims projects with health plans to facilitate recovery efforts.

         Provided ongoing reporting and data to management team regarding national configuration workload to optimize productivity and bottom-line performance.

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Lead Benefit Analyst (2011 to 2013)

         Formulated benefit grids for all new implementations and diligently partnered with configuration team to ensure benefits were configured correctly in system for claim payment adjudication.

         Championed successful implementations by leveraging proficiency in UAT, work group leadership, and seamless cooperation with reimbursement, eligibility, and medical management personnel.

Magellan Health, 2009 to 2011

Supervisor of Claims & Implementation

         Governed completed spectrum of operations within claims system implementation group consisting of seven staff members.

         Directed in-depth testing and implementation of new and existing business healthcare plans to ensure stringent adherence to corporate goals and regulatory requirements.

         Effectively interfaced with claim IT department and benefit configuration teams to ensure cohesive efforts, vital to achieving rigorous quality goals.

Patriot Coal, 2005 to 2009

Supervisor of Benefits Administration

         Helmed operations within benefits department which administered health and welfare plans for 16,000+ participants including retirees and actives under a collective bargaining agreement.

         Coached, mentored, motivated, and supervised high-performing team of benefit analysts.

         Leveraged advanced industry knowledge and experience to participate in all facets of benefit plan design for health and welfare plans.

         Applied dynamic critical thinking abilities toward reviewing medical claims appeals from employees, providers, and union representatives.

Mercer Administration, 1996 to 2004

Medical Claims Analyst Supervisor

         Supervised claims support analysts in handling referrals from claims examiners, providers, members and clients, as well as third-party liability claims.

         Steered adjudication of all high-dollar claims and initiated large case management for potential catastrophic medical cases.

Healthlink/Lahood & Associates, 1991 to 1996

Claims Supervisor / Senior Claims Examiner

         Provided influential leadership and motivation to medical claims examiners by delegating assignments, conducting regular audits, assembling plans, and administering appeals and subrogation claims.

Master of Health Administration, University of Phoenix, expected completion 2017

Bachelor of Science, Healthcare Management, University of Phoenix, 2014

Certified Human Resource Professional, University of Phoenix, 2007

Graduate, Centene Leadership Institute

Candidate, Certified Benefits Professional, World at Work

CPR and First Aid certification

Leadership Training