Alecia Henry

• Oversee staff processing regulatory complaints, ensuring adherence to guidelines from

the New York State Department of Financial Services(DFS), Attorney General (AG), and Better Business Bureau.

• Monitor complaint inventory to identify and analyze regulatory complaint trends, conduct root cause analysis, and ensure efficient case assignment.

• Ensure accurate timely resolution of complaints.

• Maintain relationships with internal and external business partners to determine effective solutions.

• Develop and manage reports to track and monitor daily operational efficiency.

• Conduct midyear and annual performance reviews for staff.

• Handle hiring and training of new staff.

• Supervise Medicare specialists to ensure adherence to Federal, State and departmental compliance standards.

• Oversee daily operation to guarantee timely responses to all member and provider inquiries in accordance with Federal requirements.

• Conduct thorough follow-ups with the staff, and both internal and external departments to address issues promptly.

• Perform daily prospective audits of responses and conduct weekly audits of pending cases.

• Review daily and weekly reports to ensure that compliance with Maximus Federal Services Inc., (MFSI), First Coast Services Operations (FCSO) and other relevant entities.

• Identify and address staff performance issues, implementing developmental and coaching strategies to enhance performance.

• Prepare and deliver quarterly and annual performance evaluations.

• Monitor staff attendance and punctuality to ensure operational efficiency.

• Investigate and resolve complaints from member, provider and other stakeholders submitted by the New York State Department of Financial Services (NYSDFS), New York State Department of Health (NYSDOH), and other regulatory bodies (i.e. Attorney General’s Office, Congressman’s Office) in a timely and thorough manner.

• Analyze and interpret HIP’s business records to address and resolve complaints effectively.

• Demonstrate in-dept knowledge of HIP’s policies, procedures, contracts, and relevant laws and regulations to address compliance issues.

• Communicated with HIP’s management, government authorities, and complainants, through verbal, written, and in-person interactions as needed.

• Draft detailed, formal written responses and provide supporting documentation to governmental authorities in response to complaints.

• Conducted comprehensive investigation of grievances, complaints and appeals from members and providers, adhering to regulations set by The National Committee for Quality Assurance (NCQA), The Centers for Medicare and Medicare Services (CMS) and the New York State Department of Health (NYSDOH).

• Monitored daily and weekly pending reports to ensure timely completion of all cases.

• Coordinate follow-ups with internal departments, delegated entities, medical groups, network physicians and external entities to facilitate case resolution.

• Prepared cases for review by Medical Director.

• Draft written responses to complainants detailing the results of the investigation and disposition of cases.

• Assist providers with claims resolution, contractual issues, credentialing, and re-credentialing processes.

• Educate network providers on company policies and protocols to support provider retention.

• Contribute to various outreach projects, includingHealthcare Effectiveness Data and Information Set (HEDIS) and Electronic Data Interchange (EDI).