(904) 434-8506 12700 bartram park blvd #2012 - jacksonville, fl 32258 abc@xyz.com

yyyyyy x. yyyyyy

yyyyyy x. yyyyyy

solutions-focused, mba-credentialed professional with solid quality auditing experience, eager to contribute dynamic staff training, team-building and interpersonal relation skills toward actively supporting the employer in optimizing operational performance.

 

profile

ø  offer progressive experience in quality auditing and employee development, with extensive management background.

ø  adept at creating, testing and implementing audit programs.

ø  proactively train, develop and direct motivated teams and create a collaborative environment conducive to achieving high levels of employee retention and job satisfaction.

ø  effectively define, develop and implement targeted qa auditing plans to maximize operational productivity, efficiency and accuracy.

ø  dynamic communication, presentation, relationship building and problem-solving abilities.

ø  excel at interacting with broad populations including senior management and staff as well as clients and external contractors.

ø  comprehensive knowledge of medical terminology, diagnosis coding, procedure codes, cpt coding, icd-9 coding, centre vu, intranet contract benefits (icb).

ø  proven ability to train and motivate dynamic employees for optimum operations.

ø  extensive experience in claims and written/phone inquiry processing in ppo, hmo, fep, nasco, and blue options.

 

recent career achievements

ø  appointed to a special membership and billing audit project and relied upon to lend expertise as the sme in training class for new associates to train on membership and billing project.

ø  successfully verified mtm standards compliance when assigned to a special membership and billing project.

ø  ensured requests were consistently processed timely and efficiently by designing and implementing an effective process improvement for reviewing quest faxes.

professional experience

blue cross and blue shield of florida                                                                                              2000-present          

quality auditor (2005-present)

  apply analytical and problem solving skills toward designing and implementing detailed audits and maintaining high dollar audits on claims $30,000 and above.

  conduct claim audits to determine proper reimbursement to clients by eligibility reviewing claims, premium, eligibility and contract interpretation.

  train, mentor and motivate new hires on procedures to handle provider and member calls, playing an instrumental role in the development of top performing team members.

  contribute advanced communication and interpersonal relation skills in diplomatically resolving conflicts and providing one-on-one coaching and continuous education to front line staff.

  proficiently manage audits for pso (hmo) diamond claims, blue options and ppo, as well as process level and individual audits for state phones and fep claims.

  product knowledge: blue card claims, federal employee policies, state account policies, and experience with hmo and ppo policies.

  technical/system experience: adviser, diamond, claims repository, imaginator superview, convergence, client letter, fep direct, convergence x, superview, siebel, stellant, and guppi.

 

 

 

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michael e. woznick                                                                                                                                  page 2 of 2

 

 

blue cross and blue shield of florida                                                                                              2000-present          

care support associate, provider care support team (2002-2005)

  ensured new availity users (providers) were properly trained and proactively communicated updates and changes regarding availity screens and blue cross blue shield of florida products.

  strategically planned and coordinated workflow to optimize use of human resources while controlling labor costs and meeting customer needs.

  investigated and managed inquiries in a timely and efficient manner, exhibiting exceptional organizational and problem solving abilities.

  product knowledge: medical clearances for hmo, ppo, fep, and nasco lines of business.

  system/technical experience: cmca, fep direct, quest, diamond, mhs, ims, service center, and nasco.

customer advocate ii, legacy claims/virtual office (2000-2002)

  contributed strong communication skills toward acting as first point of contact in responding to member inquiries, troubleshooting problems and delivering service education.

  acquired valuable knowledge and experience working with mhs(legacy), diamond and quest to process claims, as well as working on claims adjustments to ensure correct payment of claims.

  thoroughly examined, interpreted and entered detailed claims data into ims system while supporting hmo department, illustrating ability to manage multiple functions.

 

citibank                                                                                                                                          1999-2000

dispute resolution associate    

  effectively coordinated and facilitated inbound and outbound calls regarding billing disputes and claims issues, with strong focus on customer service, accuracy, productivity and efficiency.

  successfully promoted superior service and exceptional customer satisfaction by educating customers about the benefits and services available.

  conducted comprehensive research and analysis of each customer inquiry in order to promptly and effectively resolve issues and prevent escalation.

 

the athlete s foot                                                                                                                           1998-2001

supervisor/sales

  directly led a team of employees, planned and coordinated schedules and delegated assignments to optimize utilization of human capital and operational resources.

  spearheaded diverse managerial activities including training and evaluating new and seasonal employees on new procedures and guidelines.

  maintained full accountability for all aspects of store opening and closing procedures.

 

education

master s degree in business administration - university of phoenix

bachelor s degree in business management - university of phoenix

a.a.s. in retail management - orange county community college (middletown, ny)\

 

professional development/training

certified quality improvement associate (cqia) - american society for quality (asq), 12/2005 

 

technical skills

technical/systems: adviser, superview, convergence, seibel (audit purposes), mhs, ims, ics, diamond, quest, rbms, cmca, availity, lms, service center and client letter

software: ms word, excel and powerpoint, windows xp