San Jose, California, United States
Provide executive-level direction and leadership for programs devoted to the welfare of members and providers. Comprehensive experience in medical claims, call center, provider network, enrollment, configuration, appeals & grievances and positively motivate teams to exceed SLA & KPI targets. Dynamic leader with focus on operational excellence, positive staff-centric approach, and delivery of quality services for Commercial Employer, Individual Health, IPA, Medicare Advantage, and Life products. Strong communicator with empathetic interpersonal skills to facilitate effective interaction with others. Affirm enterprise adheres to quality standards, remain abreast of guidelines, regulations and laws, delivering compliant services. Exhibits exceptional organizational, prioritization, negotiation and analysis skills to consistently operate in a fast-paced environment. Core values include accountability, caring, consistency, empathy, fairness, honesty, humble, integrity, trustworthy, positive support, respect and responsibility.
• Healthcare operation oversight of Enrollment, Claims, Provider and Call Center teams • Medicare Advantage Plan Implementation & Supplement Benefit Vendor Management (Offshore & Onshore) • Manage CMS Compliance, Appeals & Grievances, and Provider Network Relations and Credentialing strategies • Project management of configuration and DOFR contractual responsibilities (including SSA) • Create and maintain policies, procedures and workflows at 1 month upon hire • Design CMS Enrollment model letters, templates & standards, prepare readiness checklist and reporting • Ensured plans meet regulatory requirements prior to go-live on effective date
• Claims, Audit, Quality Review and Medical Review administrator of Individual & Medicare products • CMS/DOI Appeal & Grievance complaint response with RCA and CAP outlined • Collaborator with actuary, compliance, enrollment, legal, premium, and FW&A colleagues • Establish SLA & KPI performance goals • Partner support to Medicare team (claims and call center) • Build strong teams via training, coaching, mentoring and professional development • Develop team restructure pilot to improve cross functional processes; incorporated enterprise wide, next quarter • Expedite online process improvement library resource in partnership with matrixed teams • Monthly (+ad hoc) presentations to senior leaders and associates
• Manage Medicare Advantage call center quality, audit and training • Improve communication with clear workflows to contact center leadership • Create performance metrics and standardized policies, procedures & reports • Develop SharePoint site to support call center operations and report detail access • Identify, create and maintain strategic and tactical initiatives based on trends • Audit & improve training manual for new hires and refresher training