Summary
Overview
Work History
Education
Skills
Accomplishments
Timeline
Generic

ALESE DUNN

Henderson

Summary

Professional consultant with focus on business process improvement and strategic planning. Proven ability to drive operational excellence and ensure project success through effective collaboration and meticulous attention to detail. Known for adaptability and reliability in dynamic environments, with skills in process analysis and stakeholder management.

Overview

13
13
years of professional experience

Work History

SR. Business Process Consultant- Delegation Audit

OptumCare
07.2024 - Current
  • Provide expert knowledge of Claims Business processes and understanding of the policy, Health Plan, and CMS compliance/regulatory requirements.
  • Conduct root cause analysis by identifying potential compliance, process, or systemic breakdowns; communicate findings to management.
  • Identify solutions to audit findings and collaborate with impacted business areas to discuss and document solutions for CAP remediation(s).
  • Build and execute remediation project plans.
  • Act as a resource to partner areas on Health Plan and regulatory requirements.
  • Policy and Procedure Management.
  • Solve complex problems and/or conduct complex analyses
  • Work with minimal guidance; seek guidance on only the most complex tasks.
  • Translate concepts/requirements into practice.
  • Provide explanations and information to others on difficult issues.
  • Project Manage regulatory and compliance related business initiatives and report to executive leadership.
  • Prepare and present Audit findings and remediation status for Operational Business Review Meeting(s).
  • Prepare and maintain meeting agendas, notes, and next steps.
  • Build and execute remediation project plans.
  • Presented findings from in-depth data analysis, providing critical insights for senior leadership decision-making processes.
  • Streamlined business processes by identifying inefficiencies and implementing best-practice solutions.
  • Coached team members on best practices, fostering a culture of continuous improvement and collaboration.

Manager Claims Business Process- Delegation Audits

OptumCare
02.2022 - 06.2024
  • Provide expert knowledge of Claims Business processes and understanding of the policy, Health Plan, and CMS compliance/regulatory requirements.
  • Conduct root cause analysis by identifying potential compliance, process, or systemic breakdowns; communicate findings to management.
  • Identify solutions to audit findings and collaborate with impacted business areas to discuss and document solutions for CAP remediation(s).
  • Build and execute remediation project plans.
  • Act as a resource to partner areas on Health Plan and regulatory requirements.
  • Policy and Procedure Management.
  • Solve complex problems and/or conduct complex analyses
  • Work with minimal guidance; seek guidance on only the most complex tasks
  • Translate concepts/requirements into practice.
  • Provide explanations and information to others on difficult issues.
  • Coach, provide feedback, and guide others
  • Project Manage regulatory and compliance related business initiatives and report to executive leadership.
  • Prepare and present Audit findings and remediation status for Operational Business Review Meeting(s).
  • Prepare and maintain meeting agendas, notes, and next steps.
  • Build and execute remediation project plans.
  • Managed and motivated employees to be productive and engaged in work.
  • Accomplished multiple tasks within established timeframes.
  • Maximized performance by monitoring daily activities and mentoring team members.

SR Claims Business Process Consult-Implementation

OptumCare
05.2021 - 02.2022
  • Provide expert knowledge of Claims Business processes and understanding of the policy, Health Plan, and CMS compliance/regulatory requirements.
  • Assess and interpret business needs and requirements to achieve and maintain compliance.
  • Review, remediation's, and responses to Health Plan Pre and Annual Delegation Audits.
  • Conduct root cause analysis of Health Plan audit findings.
  • Identify solutions to audit findings and partner with needed business areas to manage and execute remediation Project Plan for CAP closure.
  • Solve complex problems and/or conduct complex analyses
  • Collaborate with the Product Owner, Product colleagues, and other business stakeholders in annual readiness planning and implementation.
  • Work with minimal guidance; seek guidance on only the most complex tasks
  • Translate concepts into practice
  • Provide explanations and information to others on difficult issues
  • Act as a resource for others with less experience

Business Analyst- Claim Implementations

OptumCare
12.2020 - 05.2021
  • Collaborate with the Product Owner, Product colleagues, and other business stakeholders in annual readiness planning and implementation.
  • Develop and maintain detailed documentation of Health Plan and Business requirements.
  • Prepare, present and support end-user training.
  • Comply with the terms and conditions of the onboarding Health Plan contracts, company policies and procedures, and all directives.
  • Coordinate meetings between Health Plan and Business Owners to gather and execute on requirements needed for Health Plan new business implementations.
  • Manage and execute Implementation Playbooks to ensure implemented processes meet Health Plan and Compliance requirements.
  • Quality Monitoring of post implementation processes.
  • Health Plan Pre Delegation Audit responses and remediation's.
  • Improved business processes by analyzing current practices and recommending optimization strategies.
  • Interacted with internal customers to understand business needs and translate into requirements and project scope.

Claims Supervisor

OptumCare
01.2020 - 12.2020
  • Coordinate and supervise daily/weekly/monthly activities of team members including setting expectations for the team to ensure performance goals are met
  • Respond to claims escalations.
  • Identify and resolve operational problems using defined processes, expertise and judgment
  • Provide coaching, feedback and annual performance reviews as well as formal corrective action
  • Manage inventory and performance to business metrics
  • Submit P&P update requests
  • Provide expertise and/or general claims support to team in reviewing, researching, investigating, processing and adjusting claims
  • Identify and resolve operational problems using defined processes, expertise and judgment
  • Conduct analysis and identify trends and provide reports and/or executive summaries as necessary
  • Support team employee engagement and continually working to meet and/or improve vital signs results
  • Work / Lead special projects as assigned
  • Back-up for other supervisors or manager as needed
  • Identify and resolve claims processing errors/issues and trends as needed
  • Communicate and collaborate with internal and external business partners
  • Achieve applicable performance metrics (productivity, quality, TAT, utilization)
  • Assisted in the recruitment and selection of new claims adjusters, ensuring they possessed the necessary skills and expertise to excel in their roles.
  • Reduced claim processing time by implementing efficient workflow improvements and streamlining processes.

Senior Claims Representative

OptumCare
02.2017 - 02.2019
  • Review and research project or more complicated claims by navigating multiple computer systems and platforms and accurately capturing the data / information necessary for processing (e.g. verify pricing, prior authorizations, applicable benefits, coding)
  • Update claim information based on research and communication from member or provider
  • Complete necessary adjustments to claims and ensures the proper benefits are applied to each claim by using the appropriate processes and procedures (e.g. claims processing policies and procedures, grievance procedures, state mandates, CMS / Medicare guidelines, benefit plan documents / certificates)
  • Learn and leverages new systems and training resources to help apply claims processes / procedures appropriately (e.g. on-line training classes, coaches / mentors)
  • Meet the performance goals established for the position in the areas of: efficiency, accuracy, quality, member satisfaction and attendance
  • Trained and Processing on XCELYS system, and CT team
  • Claim Adjustments
  • Member Reimbursements
  • Worked productively in fast-moving work environment to process large volumes of claims.
  • Reporting Projects: PRE277 Misdirected Claims, Misdirected Claims CMS Complaint, OptumCare Collaborate Tool.

Team Lead Claims Clerk

OptumCare
02.2016 - 02.2017
  • Manage work flow of claims support team
  • Receive and prepare priority mail and ensure it gets into Facets
  • Prepares DMR and Member reimbursements
  • Manage meetings, create and update job aids and Policies and Procedures
  • Collaborating with other departments to ensure accuracy
  • Audit Support Teams work prior to being scanned into system
  • Train and teach on errors for other staff to promote growth and confidence within their function
  • Provides side-by-side coaching to improve team's productivity and quality scores for both clerks and data entry team
  • Pulls claims and correspondence batches and scans them to quality for auditing purposes
  • Reviews Formworks and incoming mail loads and coordinates staff resources to address any fluctuations
  • Acts as a technical resource to others in own function
  • At the direction of the supervisor, coordinates work of other team members
  • Identifies and resolves operational problems using defined processes, expertise and judgment
  • Track tends for possible system issues when entering data, submit request to achieve highest level of quality
  • Assisted in the creation of Support Job Aids
  • Tested and created buckets for implementation of Omega
  • Drive and coordinate WEB EX meetings with other departments on Priority items and/or discussions.

Claims Clerk

OptumCare
05.2015 - 02.2016
  • Data Entry of various claims in Formworks
  • Verifying/ locating member and provider information in Facets
  • Processing XC claim type in Facets
  • Completing Claims processing through Macess
  • Assisting with special projects
  • Assist new hires with logging into system
  • Create excel spreadsheets/ excel calendar's to track each individuals job duties to maintain organization

Lead Administrative Assistant

Concierge Compounding Pharmaceutical, Inc.
05.2013 - 10.2014
  • Administrative Assistant to the Lead Processing Technician for top priority accounts
  • Back up Processor for the Lead Processing Technician
  • Back up Auditor for the Lead Processing Technician ensuring all processes are following policies, procedures, and ensuring accuracy
  • Assisting with Special Projects for CEO's of Pharmacy
  • Customer service department lead
  • Interviewing new hire candidates
  • Training New Hires
  • Auditing service representative's calls
  • Revamping Policies and procedures to create easier work flow.
  • Data Entry
  • Using problem-solving skills to serve patients
  • Displaying leadership skills while teambuilding
  • Supervising & training new and current employees to better staff development
  • Assuring policies and procedures through monthly training exercises
  • Reporting and providing proper documentation through daily logs
  • Consistently developing meetings centered around HIPPA laws and procedures
  • Verifying accurate patient insurance, allergies, medications, and contact information
  • Utilizing multi-phone line system for inbound and outbound calls while staying in constant contact with pharmacy technicians
  • Performing superior clerical duties
  • Notifying patients on the status of their prescriptions
  • Processing patient payments and providing proper documentation
  • Emailing Doctor representatives' for missing or problematic prescriptions.
  • Assisting other departments whenever needed
  • Proof reading the technicians processed prescriptions for errors.
  • EMR experience
  • Compliance training with HIPPA
  • Assist Technician with processing of medication

Patient Coordinator/ Front Office

Matt Van Benschoten O.M.D
05.2012 - 05.2013
  • Check in in/out patients
  • Verifying and inputting patient demographics
  • Collected Patient co pays and payments
  • Verified insurance information
  • Greeted and directed patients by phone and in person
  • Provide information to patients and families ( if permitted by patient)
  • Scheduled appointments
  • Conducted Reminder calls to patients
  • Reconciled daily cash report
  • Data entry
  • All clerical, including faxing, filing, and document control

Education

General Education - College Prep

Green Valley High School
Henderson, NV
06.2005

Skills

  • Operations management
  • Business analysis
  • Organizational development
  • Policy interpretation
  • Procedure implementation
  • Compliance monitoring
  • Auditing processes
  • Decision-making

Accomplishments

  • 2019 & 2020 SuperHero Nominee
  • Emerging Leaders Program Alumni 2022

Timeline

SR. Business Process Consultant- Delegation Audit

OptumCare
07.2024 - Current

Manager Claims Business Process- Delegation Audits

OptumCare
02.2022 - 06.2024

SR Claims Business Process Consult-Implementation

OptumCare
05.2021 - 02.2022

Business Analyst- Claim Implementations

OptumCare
12.2020 - 05.2021

Claims Supervisor

OptumCare
01.2020 - 12.2020

Senior Claims Representative

OptumCare
02.2017 - 02.2019

Team Lead Claims Clerk

OptumCare
02.2016 - 02.2017

Claims Clerk

OptumCare
05.2015 - 02.2016

Lead Administrative Assistant

Concierge Compounding Pharmaceutical, Inc.
05.2013 - 10.2014

Patient Coordinator/ Front Office

Matt Van Benschoten O.M.D
05.2012 - 05.2013

General Education - College Prep

Green Valley High School

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