SUMMARY
Seeking challenging management position in the service or health care industry
PROFESSIONAL EXPERIENCE
Horizon Blue Cross Blue Shield of New Jersey 1995 to 2012
Contract Analyst, EEi4 Project (concurrent with position below) (4/01/2010 to 8/01/2012)
• Conducted quality audit of static benefits information by comparing source documentation to the data located on the static benefit audit systems for all lines of insurance business
• Performed triage/data correction and loading of benefit coding updates for employer groups including Health Care Reform, NJ Minimum Standards, and Mental Health Parity
• Created documentation utilized to train new hires on the Scorecard Remediation process
• Attained 98.21 percent overall quality scores, and maintained zero coding errors year-to-date
• Recognized as “Most Valuable Loader” for excellent quality in 2012
Instructional Design Analyst, Service Training & Development (11/12/2007 to 10/20/2011)
• Applied Instructional Design methodology to create and maintain classroom and e-Learning programs and materials for Horizon sites, and at remote vendor locations
• Coordinated with Training, and Knowledge Management teams to provide input into learning solution program design and implementation
• Collaborated with Coaching, Quality and Operations during and after training periods to ensure optimal learning experience, smooth transition, and on-going monitoring
• Conducted gap analysis and reviewed data/metrics to determine if training solutions were necessary and what type was required
• Suggested training alternatives and provided educational guidance to various departments including Provider and Member Services, Workers’ Comp, and Accounts Receivable
• Assisted with the modification of design resources/schedules in response to staffing issues and/or business needs
• Represented department at cross-functional meetings, and workgroup sessions
• Chaired Universal Customer Service Workstation (UCSW) Service Request Documentation Workgroup and successfully implemented all recommendations
Physician Relations Representative II, Network Operations (8/23/2003 to 11/11/2007)
• Managed and investigated various claim projects for Network Operations Department
• Team Lead concerning Complaint Tracking process - ensured accurate monthly reporting, and resolution of provider and member complaints within mandated timeframes
• Supported field staff, researched and resolved physician data file issues on all claim systems
• Resolved physician claim problems, and electronic claim (EDI) issues
• Collaborated with tech teams to successfully automate the Complaint Tracking process
• Met with VIP physician groups in order to resolve claim, pricing and enrollment issues
• Participated in workgroups including Complaint Handling Process Improvement, UCSW User Steering Committee, UCSW Best Practices, and also acted as UCSW User Advocate
• Trained field staff on various systems including UCSW, NASCO and QBlue
• Investigated, resolved and drafted responses to Executive Inquiries and Special Letters
Physician Relations Representative I, Network Operations (1/13/2001 to 8/22/2003)
• Processed physician data maintenance requests, and managed Team Lead responsibilities regarding oversight of workflow for Network Operations Department
• Resolved physician claim and network issues for all lines of business
• Tracked physician and member complaints, reported results on quarterly basis, and provided various reporting and data analysis
• Organized provider education seminars and prepared Pow...
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