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Yyyyyy x. yyyyyy


0000 xxxxxx xxxx , xxxx , xxxxx 00000 914-235-7108


Management Professional


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 heading special project efforts. Skilled in working within a team environment across multiple departments and organizational facets. Capable of effectively prioritizing daily functions with a comprehension of operational issues in a fast-paced setting. Capable of assessing and measuring the efficacy of programs. Adept in 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 an Associate Director of Operations role in a nonprofit setting that will allow for continued growth and development in helping others.



Core Skills

Community Leadership | Building Awareness | Operations Coordination | Support Services Coordination

Program & Office Management | Procurement & Budgeting| Recordkeeping & Reporting | Critical Thinking

Continuous Improvement | Contracts | Negotiation | Client Education | Supervision | Human Resources | Hiring

Interviewing | Training & Development | Performance Assessment & Recognition | Customer Needs Assessment

Communication | Project Management | Strategic Planning | Problem Analysis | Cross-Functional Teamwork

Conflict Resolution | Organization | Time Management | Prioritization | Workflow Planning




Windows | 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 | Citrix | Facets | Microsoft Excel, Word, PowerPoint, SharePoint, Outlook


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




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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