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Candidate Info
15
years in workforce
4
years at this job
BS
Business Administration
Healthcare Consultant
Work within Patient Financial Services and all levels of the hospital revenue cycle including denials management, write-off prevention, and billing and collections improvement
- Identify process breakdowns in the hospital billing, collections, and cash posting processes, and implementing innovative solutions to address new issues that arise
- Discovered population of aged accounts that needed resolution which helped relieve A/R by $4M
- Implemented payer escalation process with top insurers resulting in payments of $2M
- Trained representatives to use our tool resulting in a 47% increase in productivity
Candidate Info
14
years in workforce
2
years at this job
Technology
Healthcare Consultant/project Manager
Established work plan for each phase of project and arranged for recruitment and assignment of project personnel.
- Managed activities and project personnel to ensure project progressed on schedule and within prescribed budget.
- Reviewed status reports prepared by project personnel and modified schedules/plans as required.
- Prepared project reports for management, clients and others.
- Consulted with clients to determine their needs and priorities.
- Detailed knowledge of Medicare, Medicaid, Managed Care, HMO's, PPO's, Workers Compensation and BC/BS insurances.
Candidate Info
14
years in workforce
2
years at this job
BA
Journalism
Healthcare Consultant
Collaborated with Community Health Centers to help form an IPA to obtain managed care contracts
- Developed comprehensive Provider Manuals
- Created robust quality goals and metrics for physician groups and health plans.
- Established comprehensive Bonus Criteria for physicians meeting strict financial and quality goals
- Managed Care IPA development
Candidate Info
19
years in workforce
8
months at this job
BS
Healthcare Management
MA
Accounting
Healthcare Consultant
Assumed an interim management role responsible for a large operational staff and $600M in receivable across all healthcare payers.
- Engaged CFOs of all 21 hospitals within the Health System and Leadership staff at various Payers to increase cash flow.
- Led operations and strategic directions with full responsibility for bottom-line factors, including long range planning. Financial Analysis, P & L Management and Client Relations.
- Staff Management -select and hired an exceptional staff. Provided comprehensive professional development and succession planning to ensure reaching challenging operational goals.
- Exceeded Monthly Collection Goals for consecutive months.
Candidate Info
16
years in workforce
16
years at this job
Insurance Course
Medical
Healthcare Consultant Independent
Worked for numerous corporations and organizations as a contracted employee, providing support for various out of state hospitals with reimbursements and accounts receivable assistance. Developed extensive project management and skill sets in the following areas:
- Follow-up, collections, cash posting, adjustments, write-offs in addition to reconciliation.
- Increased revenue through loss prevention and cash acceleration and denial management methodology
- Resolved patient financial issues by establishing payment plans, in addition to financial assistance, for Hospice patients and their families.
Candidate Info
5
years in workforce
9
months at this job
BA
Anthropology & International Peace Studies
MBA
Healthcare, Marketing
Senior Associate, Healthcare Consultant
Served as the primary relationship manager for portfolio of 14 hospital and health system clients; worked with client team to enhance revenue cycle performance through data-driven process improvement and risk mitigation
- Launched 7 new clients in fall 2013; conducted web-based product instructional sessions, performed initial data assessment, and presented recommended action plan to senior leadership and staff to attain buy-in for ICD-10 preparation
- Managed project timelines and ensuring that clients generated significant value from partnership with the Advisory Board
- Educated executives and staff on ICD-10, clinical documentation, RAC programs, and revenue impact topics; identified areas of opportunity and risk to prioritize strategies within long-term plan
- Analyzed operational, clinical, and financial performance and diagnosed issues/causes to provide recommendations and drive
Candidate Info
20
years in workforce
13
years at this job
BA
Business Administration
Independent Healthcare Consultant
for new coverage area for Managed Care Plan
- Developed and maintained referral relationships between physicians and Radiology Group
- Developed and implemented marketing strategies to recruit Providers into local transportation IPA
- Developed and maintained relationships with Insurance Companies on behalf of Provider offices. Including all phases of contracting, credentialing, and problem resolution
- Insurance claim resolution for Providers and insured individuals
- Managed all aspects of regulatory audit for Insurance Company
Candidate Info
22
years in workforce
5
years at this job
Hotline Specialist / Healthcare Consultant
- Collected information, researched inquiries, responded to customers and field representatives and recorded all data for these calls and e-mails coming in for the hotline in an Access database
- Provided current and accurate coding and reimbursement information to customers and field representatives from both professional/physician and an outpatient hospital perspectives
- Performed detailed ICD-9 and CPT audits with deliverables to the client
- Provide coding and coding support to various customers as needed
- Extensive experience with Microsoft Office products including Word,
- Ability to multi-task. Extremely organized and self-motivated
Candidate Info
9
years in workforce
2
years at this job
BA
Bachelor of Arts
MA
Master of Arts
Independent Healthcare Consultant, New Jersey
Consulted as a Healthcare subject matter expert to the client, a patient advocacy company.
- Formulated scope and objectives document for the system (patient advocacy portfolio).
- Served as a primary liaison between business team, users, and technical personnel to assure that application
- Documented and performed workflow analysis on the business area processes, systems, information flows,
Candidate Info
3
years in workforce
2
years at this job
BS
Human Services
MS
Public Service Administration / Health Administration
Independent Healthcare Consultant
- Facilitated project assistance for designated healthcare organizations.
- Evaluated office operations of a medical practice. Developed and implemented action initiatives and streamlined recommendations in the areas of policy and procedures that resulted improved customer service and quality care.
- Secured physicians for healthcare marketing firm conducting pharmaceutical studies.
- Researched and investigated contacts within nursing and medical education departments at numerous hospitals and outpatient centers.
- Developed and implemented strategic telemarketing protocol to enhance company sales of educational products.
Candidate Info
7
years in workforce
2
years at this job
AS
Business Administration
BS
Management
Oral Healthcare Consultant, Expert Sales Department
- Created, implemented and adjusted territory sales plan and routing schedule to maximize reach, frequency and influence of dental clinicians
- Utilized promotional budgets to execute on-site lunch-and-learns with target dental offices to educate on condition awareness and brand benefits
- Managed physical and remote sample inventories to expand patient reach and trial
- Actively participated in divisional events, remote learning modules and national meetings to improve product communication and implement new promotional materials
- Proactively communicated competitive landscape to internal marketing teams
- Partnered with Local Hygiene Programs to build disease-state awareness among both student bodies and practicing Registered Dental Hygienists
Candidate Info
11
years in workforce
1
year at this job
Healthcare Consultant
Work with senior executives to define focus areas for performance improvement and document results.
- Proactively analyze client data to assess opportunities for ROI and market share improvement.
- Define, document, distribute and implement best practice workflows to both members and internal constituents
- Co-manage a pool of 20+ system-wide clients and 50+ individual organizations accounting for $8MM+ of contract value.
- Create client facing collateral for executive on-site presentations.
- Serves as a mentor for new hires.
Candidate Info
46
years in workforce
5
years at this job
BS
Aeronautical Engineering
Senior Specialty Healthcare Consultant
Manage the sales of an injectable biologic medication to Neurologists for the treatment of Multiple Sclerosis.
- Received Area Performance Award in 2011 and 2012 for outstanding performance in a number of strategic areas.
- Finished 13th in the nation out of a total of 95 sales reps in total new prescription production in 2011.
- Moved territory rank from 85th to 33rd during first year in territory.
- Ability to determine new business potential in a decreasing market.
- As team leader provides strong support and guidance and deals effectively with any issues and concerns of his team.
- Developed and presented various workshops to team members relative to performance improvement and has successfully mentored employees ongoing.
- Provides appropriate education to customers on the various aspects of the pharmaceutical medicines being sold in order to achieve annual sales targets.
Candidate Info
28
years in workforce
5
years at this job
AS
Accounting
BBA
Finance / Business Managment
Independent Healthcare Consultant
- Perform compliance reviews on cost reports and report financial impact of changes in reimbursement regulations to facilities.
- Consulted on changes to Managed Care Contract and the impact on bottom line of area Hospitals
- Reviewed cost reports prior to submission to the Fiscal Intermediary to ensure compliance with Medicare regulations
- Performed compliance and regulatory reviews and analyzed and reviewed all unsettled Medicare Cost Reports to ensure compliance with CMS (center for Medicare and Medicaid Services) regulations.
Candidate Info
5
years in workforce
5
years at this job
AS
Computer Programming
Healthcare Consultant
- Supervised data collection and pre-implementation preparation of the Ancillary Departments for a TDS 7000 system install at a 750-bed hospital.
- Modified a TDS 4000 system at a 550-bed hospital for a release upgrade to a TDS 7000 system.
- Designed interfaces specification at a multi-facility medical center for a two-way interface from Media-Mouse (Emergency Patient Management System) to TDS 4000 system through an Interface Server (CAI/PIPE).
- Designed interface specification at a multi-facility medical center for a two-way interface from SMS Patient Registration to TDS 4000 system through an Interface Server (CAI/PIPE).
- Designed financial interface specification (DBEX) at a large multi-facility medical center for a one-way interface from TDS to SMS Patient Financial through an Interface Server (In-house COBOL).
- Designed two-way ADT/Order entry interface specification (RFT/PARSER) at a 450-bed hospital from TDS to SCC SoftLab through a Cloverleaf Engine (HL7).
Candidate Info
33
years in workforce
18
years at this job
BS
Biology
Senior Professional Healthcare Consultant
Promoted from Professional Representative to Senior Professional Healthcare Representative in only three years due to sales and leadership performance
- Responsible for sales and operations and leading a 4 million dollar annual business
- Profiled and developed call cycles by micromarketing
- Consistent achievement with 14 billion dollar product and primary products
- Leader within the district; developed contests to motivate team members, and the district computer expert.
- Successfully sold products in multiple disease states including: Cardiovascular, Diabetes, Antibiotics, Urology, Allergy/Immunology, HIV, and Conscious Sedation
- Analyzed managed markets to better target sales messaging
- Cultivated new physician speakers within product portfolio for utilization within district
Candidate Info
7
years in workforce
1
year at this job
BS
Biomedical Sciences
MBA
Business Administration
Healthcare Administration
Healthcare Consultant
Provided project management expertise for revenue cycle, EMR transition, and general healthcare business services.
- Assisted with research for PPACA and effects on business operations for various industries.
- Several short term project consulting engagements with local client base.
- Provided administrative expertise in setting up patient access processes for rural dentistry and medical clinics in Honduras.
Candidate Info
18
years in workforce
3
years at this job
Billing Manager / Healthcare Consultant
Perform medical billing across numerous specialties including ophthalmology, family practice, physical therapy, et cetera
- Supervising Billing Department employees
- A/R Audit / Collections - reduce client A/R from 10%-65%
- Provide clients with monthly and yearly performance reports and provide recommendations to achieve operational goals
- Perform healthcare business consulting duties including credentialing, contract review, reimbursement proposals and negotiation
- Provide clients with all start-up materials and documents pertinent to revenue cycle management
- Train client's employee in revenue cycle management, billing and operational 'best practices'
- Awarded several financial and positional promotions from management due to superior performance
Candidate Info
17
years in workforce
6
years at this job
BA
Accounting
Senior Healthcare Consultant
During my six years at [company name] I was the lead consultant responsible for projects that included:
- Preparation and analysis of feasibility studies, impact analysis, and Certificate of Need (CON) applications. Certificate of Needs are health care service plans.
- Emphasis in business planning; clinical need, service utilization, market share, and operational and financial impact analysis. Analysis of payor mix (Medicare, Medicaid, Insurance, Private payors) by product line.
- Completion of over 30 CON applications for clients throughout the Southeast for new or expanded services including but not limited to new hospitals, major hospital renovation projects, open heart surgery, neonatal and women's services, ambulatory surgery, rehabilitation, Positron Emission Tomography, nursing home, home health, and hospice services.
- Analysis of various methods of calculating funding for workers compensation claims.
- Litigation support
- Clients included but are not limited to large hospital systems, freestanding hospitals, critical access hospitals, physician practices, home health providers, Managed Care Organizations, and government agencies.
Candidate Info
12
years in workforce
1
year at this job
BA
Bachelor of Arts
MA
Business Administration
Independent Healthcare Consultant
Contracted by a leading revenue cycle management firm to provide operational insight and expertise through the development and implementation of a comprehensive Process Excellence project with the end goal of building a next generation model that is focused on revenue acceleration and cost savings through the enhancement of the firm's people, processes, and technology.
- Project plan development began in January 2014. Final plan submitted to steering committee in April 2014. Expected annual revenue lift through acceleration and cost savings projects to exceed $2.8 million. Worked directly with the Division President of Operational Analysis and the Vice President of Process Excellence to develop a work plan, associated project task lists, and measurement standards.
- Final work plan encompassed the procurement and deployment of technology in upfront screening processes; the remodel of automated flow managers, IVR and letter campaign usage, work-in-progress queue set-up, and account prioritization hierarchy in follow up production; and the level-set of current key performance indicators and the creation of next generation key performance indicators for management scorecard reporting.
- Successfully led project work sessions with the Transformation team that consisted of Eligibility Division Presidents, Regional Vice Presidents and representatives from Human Resources and Information Technology.
- Managed pilot implementation at test sites located in both Eligibility divisions. Responsibilities encompassed the oversight of the build and test phase of the new model components, the management of the project task list, the development and deployment of training modules, the creation of reporting tools for the pilot's operations team, and the identification of KPI baselines to measure the impact of the next generation model at each test site.
Candidate Info
12
years in workforce
4
months at this job
QM Healthcare Consultant
Performed accurate and comprehensive medical record reviews
- Maintained confidentiality and complied with HIPPA
- Performed onsite medical record reviews at provider offices
- Reviewed/abstracted electronic and paper charts to obtain specific
- Performed offsite medical record reviews via providers EMR system
Candidate Info
12
years in workforce
3
years at this job
BA
Psychology And Business Administration
Senior Healthcare Consultant
Provide Operational Leadership and Management for fast-paced home healthcare company. Set annual financial goals and project needs for new admissions and staff. Review weekly financials including cash flow, client billing, and payroll. Train and mentor recruiters, scheduling coordinators, and human resource coordinators. Create and monitor procedures to continually increase efficiency and ensure compliance with state regulations.
- Network to build relationships with referral sources resulting in new client admissions and increased sales.
- Liaison between office clinicians, physicians, and insurance companies as needed to obtain client insurance authorizations.
- Utilize conflict resolution skills to ensure grievances or compliance concerns are properly resolved.
- Work with clinicians to coordinate medical care for clients.
Candidate Info
9
years in workforce
7
months at this job
AA
Computer Information Systems
Frasier Healthcare Consultant
- Medicare collections and follow up.
- Implemented and maintained the database for the Medicare secondary billing system MCE (Medicare Claims Express).
- Medical Management operating system utilized. Also perform day end batch closings.
Candidate Info
20
years in workforce
3
years at this job
BA
Anthropology
BSN
Nursing And Biology
BA
Anthropology
Healthcare Consultant/interim Vice President Roles
Started business as a healthcare consultant for Care Continuum processes as well as Care and Disease Management program development for large Managed Care corporations and Acute care hospitals and systems
- Served as Interim VP of Medical Management for year long periods to turn around struggling medical management systems. Hired and trained permanent replacements for the ongoing role of VP, Medical Management
- Worked with both acute and post-acute hospital facilities and systems to provide analysis, full assessment of opportunities for the facilities and targeted implementation plans.
- Provided support and plans for system integration (multi-facility system integration) and developed plans for performance improvements in the areas of length of stay, Acuity/Care Mix Index, Clinical Programming development, overall performance improvement and worked with the facility team to implement and support the success of the plan.
Candidate Info
22
years in workforce
1
year at this job
BA
Medical
Healthcare Consultant / Administrator
Initial evaluation of the assigned patient and reaching the conclusion of the diagnosis also managing the patient according to the diagnosis.
- All acute patients hospitalized and manage the patients till discharge.
- Assist Surgeons for the surgeries for acute and emergencies.
- Managing ICU patients for acute chest and abdominal pain.
- Regular routine rounds for in patients and later joining the rounds with the Attending Physician.
Candidate Info
12
years in workforce
6
years at this job
BS
Triple Major
Healthcare Management; Addtl Certificate
Health Services Administration)
Healthcare Consultant
- Conduct Independent Medical Examinations for psychiatric patients suffering from a plethora of medical conditions and disorders, including Major Depressive Disorder, Schizophrenia, Substance Abuse, Substance Addiction, and a variety of personality disorders.
- Assist in the Assessment, Diagnosis, and Recommendations for a variety of mental health patients fairly autonomously.
- Assist in the creation of Full Psychiatric Evaluations for a variety of patients from different backgrounds fairly autonomously.
- Assist in the analysis and assessment of medical/legal cases in a fairly autonomous fashion.
- Help in the assessment, analysis, and review of large volumes of medical records associated with psychiatric evaluations autonomously.
- Assist in the implementation of the EMR Upgrade projects.
- Physician Liaison/Sub-Principle Investigator in a 2011 Research Study focused on the use of Non-Stimulant Medications in the treatment of childhood & adolescent ADHD (INTUNIV ADHD Study).
Candidate Info
3
years in workforce
2
years at this job
BS
Biomedical Sciences
MA
Epidemiology
Healthcare Consultant
- Act as Project Lead on Community Health Needs Assessments and Physician Needs Assessments
- Conduct meetings with and present report findings to high level hospital administration members
- Schedule and conduct interviews with hospital and community organization leaders
- Analyze and interpret qualitative data
- Facilitate focus groups emphasizing community health discussions
Candidate Info
14
years in workforce
6
years at this job
GE Healthcare Consultant
Provide outstanding customer service to client
- Monitor and allow employees, visitors, and other people to enter or leave buildings
- Establish and maintain relationship with clients daily by telephone or in person
- Write reports of activities/problems, such as property damage, theft, or unusual events
- Review and approve batch orders to file.
- Answer telephone calls from clients and take messages for management
- Answer questions, and provide information during business and non-business hours
Candidate Info
33
years in workforce
12
years at this job
BS
Health Administration
MBA
Management Specialization
Information Management
Healthcare Consultant
Audit and abstract medical records for appropriateness of coding and documentation
- Manage revenue cycle to maximize efficiency and profitability
- Optimize revenue through increased reimbursement methodologies
- Provide training and education of healthcare policies and procedures
- Create and implement compliance plan
- Use good sound financial and medical practices to troubleshoot and solve
- Integrate health information technology and systems with reimbursement approaches
- Participate in strategic planning and business development with members of the leadership team to launch and monitor new program initiatives
- Recommend changes in patient care and billing standards to meet requirements prescribed by accrediting agencies
- Guide and advise the development of client proposals and corresponding implementations
Candidate Info
14
years in workforce
11
years at this job
BS
Psychology
MS
Health Services Administration
Healthcare Consultant
- Function as lead project manager on projects involving healthcare market, business planning and financial analysis with clients spanning the full continuum of care including acute care hospitals and health systems, rehabilitation hospitals, psychiatric hospitals, long term acute care hospitals, skilled nursing facilities, hospice programs and assisted living facilities.
- Integrally involved in the strategic planning for healthcare providers including expansion, diversification and acquisition analysis, strategic market positioning and market evaluation, compliance and regulatory support, community needs assessments and business development.
- Spend considerable time on certificate of need planning and finance, including preparation of CON applications in several states, development of trial exhibits related to litigation support services and evaluation of the need for various proposed services.
- Provide planning and financial litigation support services and trial strategy for a wide range of healthcare facility types related to matters under the jurisdiction of the Florida Division of Administrative Hearing.
- Conduct detailed operational and financial analysis for the performance of various characteristics at hospitals, rehabilitation facilities, psychiatric facilities and other healthcare providers.
- Provide clients with data and information on their market dynamics, opportunities which may arise, and general news reports on their communities and competitors on an ongoing basis.
Candidate Info
17
years in workforce
2
years at this job
Healthcare Consultant
- Performs complete analyses within the scope of the project from the simple to the complex.
- Product development; impact analysis.
- Analyze reports; structure methodologies, make recommendations to increase proficiencies within both technical and procedural areas, summarize the findings, and apply the findings to the project.
- Continuously develop and implement process improvements to consistently improve business processes which will then meet new and changing goals and objectives;
- Areas of concern: Denial Management, Front End Registrations, Billing, Collections, 5010 readiness, Obama Care Act (PPACA); Managed Care loop holes/closing the gaps
- Manages a project which includes managing the executive relationship, organize the team, structure the work plan/flow, implement fail safe to effectively maintain appropriate work plan, introduce the work to the client and develop any implications for the client. Maintain Effective team building.
- Manages SBU relationships by building a development strategy and deepen trust-based relationships. Drive the business impact of the project or more than one project.
- Manages company relationships by becoming the trusted advisor to the CEO and the Board. Improve total company performance. Lead multiple engagements for the client over time
Candidate Info
11
years in workforce
1
year at this job
AS
Project Management
Independent Healthcare Consultant
Responsible and accountable for the coordinated management of multiple related projects directed toward strategic business and other organizational objectives.
- Define and initiate projects, and assign managers to manage cost, schedule, and performance of component projects, while working to ensure the ultimate success and acceptance of the program.
- Design and manage windows based environments, hardware installation, setup and troubleshooting HL7 servers and desktop, configuration of servers, loading patching and updating users, groups and policy creation.
- Assisting users by providing tier 2/3support for all escalated desktop and server support issues, sustaining applications.
- Responsible for anti-virus, implementing new solutions and technologies that affect the windows environment. Assist clients with server disaster recovery and planning, assist in supporting centralized domain administration and active directory support.
- Consulting and supporting providers, electronic medical records and marketing voice recognition software interface to the electronic medical records
Candidate Info
57
years in workforce
5
years at this job
BA
Speech-language Pathology
MA
Communication Disorders
Language Pathologist/healthcare Consultant, Alabama and Georgia
Speech-language pathology consultant providing clinical speech, cognitive language, and dysphagia services to geriatric patients residing in long term care centers, home health patients, and residents residing in assisted living facilities and retirement communities.
- Provide patient/caregiver training and treatment consultations with families, facility team members, and community agencies relative to patient care needs and rehab options for speech, language, and dysphagia.
- Develop, implement, and monitor therapeutic treatment programs for patients and facility staff per rehab needs.
- Consult with nursing staff, primary care physicians, dieticians, residents and family members to provide clinical speech, language, and dysphagia management and treatment strategies/options.
Candidate Info
21
years in workforce
3
years at this job
BS
Psychology
MA
Health Administration Informatics
Senior Healthcare Consultant
Senior Project Manager for Integrated Care Management/Health Information Management Area. (FEP)
- Responsible for managing multiple cross-functional projects and associated deliverables related to data analysis. This includes, but is not limited to, assessing the local plans benefit cost needs, analyzing claims and disease management data, preparing ad-hoc reports, and participating in the consultative process that identifies actionable findings and offer customized recommendations resulting in value-added resources and information for all plans.
- Functioned as Subject Matter Expert and/or Business Lead in advising and supporting plans regarding data analysis and reporting in an effort to support benefit cost, network and utilization management initiatives.
- Responsible for analyzes, synthesizes and/or maintenance of complex databases and identifying and assessing opportunities for process/systems improvement as it pertains to Health Information Management.
- Responsible for executing projects and deliverables that cross many functional boundaries; Conduct complex analyses, interpret findings, develop recommendations, as well as provide analytical support to the Health Information Management Benefit Cost area, in-house Networks area, FEP plans, and other business partners and internal customers as needed.
Candidate Info
12
years in workforce
4
years at this job
BS
Management
Federal Healthcare Consultant
- Performs comprehensive medical record and claims reviews to make payment determinations based on Insurance coverage, coding, and utilization of services and practice guidelines.
- Utilizes electronic health information imaging and inputs medical review decisions by electronic database module.
- Makes clinical review judgment decisions based on clinical experience when applicable.
- Plans, develops and manages administration of routine to moderately complex claims programs to ensure proper claims policies, practices and procedures are adhered to.
- Utilizes Microsoft Word, Excel, & Access templates as associated source input for claims review.
- Manages and approves small to medium sized billing statements, claims and associated administrative activities to ensure compliance with laws, regulations, policies agreements, and contractual arrangements.
- Plans and implements procedures to adjust claims when original demographic, sponsor or charge information is in error; monitors and controls resubmission of denials, rejections and appeals.
- Manages, and as necessary, intercedes with third parties in unusual situations involving payment or adjustment of charges on accounts; consults with departments concerning services which affect collection of charges.
- Manages, coordinates and prepares periodic reports on department activities including productivity, cash collections, and status of accounts receivable, unbilled accounts, allowances, adjustments, related functions, audits and financial reporting.
Candidate Info
44
years in workforce
4
years at this job
Medical & Dental
Business
KPIC Healthcare Consultant
- Develop and implement operational processes, policies and procedures for claims processing and customer service operations, based on the interpretation of state, federal and local laws and regulations and industry standard practices
- Assist with escalated medical and dental claims, pharmacy audits and other operational audits to ensure accurate adjudication of claims, appropriate internal controls and adherence to federal, state and local regulatory requirements
- Manage and oversee the identification, documentation and resolution of escalated issues in support of KPIC products and regulatory requirements. Performs in depth root cause analysis to determine process improvements necessary either w/in KP or at contracted vendor
- Strong time, meeting and organizational skills
- Research, resolve and respond to escalated claims issues, complaints and grievances and appeals. Communicates with members, employer groups, brokers and carrier representatives to resolve claim and customer service issues
- Provide summary reports/scorecards on productivity and quality to KPIC Leadership on a regularly determined basis
- Identify productivity and quality issues with claims processing and customer service vendors, based on results of claim audits and review of performance metrics. Develop and implement programs for continuous quality improvement. Responsible for communicating, coordinating and tracking effectiveness of improvements and reporting results to KPIC management team and vendor partners
- Provide guidance to the KPIC team members and Regional team members on complex claim and customer service issues, drawing on previous insurance industry experience and knowledge of industry standard practices
- Work with claim payment and customer service vendors to ensure consistency in implementation of KPIC policies and timely and accurate processing of claims and customer service inquiries in accordance with established performance standards
- Provides daily leadership, coaching, and guidance to KPIC's regional and external third party vendors in achievement of claims payment and customer service excellence.
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