Amy Baker
Bartlesville,OK
Summary
Accomplished Director of Operations with a proven track record at Concierge Third Party Administrators, showcasing expertise in operational efficiency and strategic vendor partnerships. Skilled in Microsoft Office and adept at project management, I excel in leadership and problem-solving, significantly enhancing organizational productivity and client satisfaction.
Overview
36
36
years of professional experience
Work History
Director of Operations
Concierge Third Party Administrators
05.2017 - 10.2024
- Implemented the start up of this TPA for self-funded clients to include finding and setting up the claims operating system, getting clients set up in the system with the appropriate benefits and rates, eligibility, invoicing, and any other applicable information unique to each client.
- Established strong partnerships with vendors, suppliers, and key stakeholders to improve collaboration and ensure alignment with business requirements.
- Review and implement Pharmacy Benefit Manager (PBM) contracts, set up, and changes.
- Analysis of PPO contracts/discounts to ensure the clients have the best access and discounts available.
- Assisted in recruiting, hiring and training of team members.
- Oversaw daily operations across multiple departments, ensuring seamless coordination and efficient execution of tasks.
- Oversaw successful implementation of operational strategies and policies to drive organizational growth and productivity.
- Mentored and coached team members to foster productive and engaging work environment.
- Delivered exceptional customer experiences by implementing strategies focused on meeting evolving needs and expectations.
- Worked collaboratively with functional leaders to implement new procedures and corrective actions to improve quality.
- Implemented the start-up of new clients to ensure a smooth and successful implementation.
- Renewal of clients to include new vendors when applicable, open enrollment, enrollment portal updates, enrollment guides, and system updates.
- Prepared monthly, quarterly, and annual reports for clients.
- Oversaw claims processing, client check runs, and review of client claims funding.
- Established and monitored quality assurance standards to achieve operational excellence.
- Evaluate internal/external audits to ensure accuracy.
- Managed all aspects of our fully-insured clients to include shopping benefit plans, rates, contracts, employee education, and enrollment.
Client Service Representative
HealthSmart
10.2012 - 05.2017
- Handled all customer needs related to any product line in a knowledgeable and effective manner, which may include but not limited to, Medical, Dental, Vision, FSA, HRA, COBRA, and Stop Loss.
- Knowledgeable and proficient in the use of HealthSmart benefit and claims operating systems based on client assignments and work assignment.
- Completed client related reports and reviews with Account Management and appropriate Operations Management Teams on a monthly basis to drive quality improvement, process improvement and client satisfaction.
- Elevates plan discrepancies and significant client issues immediately to Operations Management and the Account Executive based on established protocol.
- Assists Customer Experience Team Managers in problem solving and resolution of difficult customer inquiries.
- Prepared correspondence and reports in a clear, concise and grammatically correct manner utilizing Microsoft Excel, Power Point, Access and other similar software programs.
- Prioritized multiple high visibility and impact issues and meet established deadlines while maintaining a high level of accuracy, quality and overall service excellence.
- Pro-actively address, with internal teams, on client satisfaction, quality and process issues that are recognized by the ESR team via tracking and trending of all issues.
- Processed claim corrections on escalated issues and high priority issues which may include overpayments, refunds, stop-loss payments, adjustments and check traces in a timely manner.
- Participated in all Customer Experience training programs that will assist in providing superior Customer Service.
- Adhered to and supported the corporate policies and procedures of HIPAA, which includes the appropriate communication (electronic and non-electronic), workstation handling, and protecting of PHI.
Director of Operations
Mutual Assurance Administrators, BMI-HealthPlans
08.2007 - 10.2012
- Prepare and review operational reports and schedules to ensure accuracy and efficiency.
- Prepare, review, and balance client financial reports on a monthly, quarterly, and annual basis.
- Analyze internal processes and recommend and implement procedural or policy changes, goals, and objectives to improve operations.
- Manage staff, preparing work schedules, assigning specific duties for work flow, based on work priority and skill of personnel.
- Monitor employees' work levels and review work performance.
- Counsel employees about work levels and review work performance.
- Recommend or initiate personnel actions, such as hires, promotions, transfers, discharges, and disciplinary measures.
- Meet with department heads, managers, supervisors, and others, as need to resolve problems.
- Direct daily operations of departments, analyzing workflow, establishing priorities, developing standards and setting deadlines.
- Meet with vendors and suppliers to discuss products.
- Assist with renewal of clients such as review utilization reports and make recommendations of potential benefit changes.
- Oversaw year-end procedures, such as reinsurance contracts and claims flow to ensure all procedures are completed. Ensured that payments made by the clients are reimbursed by the Reinsurance Carrier.
- Reviewed and implemented Pharmacy Benefit Manager (PBM) contracts and changes.
- Analysis of PPO contracts/discounts to ensure the clients have the best access and discounts available.
- Client meetings and education of client employees of Plan benefits and changes.
- Oversaw automation of claims, eligibility, and reports.
- Evaluate internal audits to ensure accuracy.
Claims Manager
BMI-HealthPlans
07.1997 - 08.2007
- Resolve customer complaints and answer customers' questions regarding policies and procedures.
- Supervise the work of office, administrative, or customer service employees to ensure adherence to quality standards, deadlines, and proper procedures, correcting errors or problems.
- Provide employees with guidance in handling difficult or complex problems and in resolving escalated complaints or disputes.
- Implemented corporate and departmental policies, procedures, and service standards in conjunction with management.
- Train and instruct employees in job duties and company policies or arrange for training to be provided.
- Evaluate employees' job performance and conformance to regulations and recommend appropriate personnel action.
- Recruit, interview, and hire employees.
- Interpret and communicate work procedures and company policies to staff.
- Prepare and issue work schedules, deadlines, and duty assignments for office or administrative staff.
- Research, compile, and prepare reports, manuals, correspondence, and other information required by management.
- Prepare, review, and balance client financial reports on a monthly, quarterly, and annual basis.
- Coordinate activities with other supervisory personnel and with other work units or departments.
Claims Processor
BMI-HealthPlans
05.1988 - 07.1997
- Review insurance policy and claims to determine coverage.
- Provided customer service.
- Process medical, dental, Rx, and vision claims to ensure proper payment.
- Verify eligibility of Plan participants.
- Protect the security of medical records to ensure confidentiality is maintained.
- Review records for completeness, accuracy and compliance with regulations.
- Enter data, such as demographic characteristics, history and extent of disease, diagnostic procedures and treatment into the claims system.
- Resolved or clarified codes and diagnoses with conflicting, missing, or unclear information.
- Requested additional information as need to make a benefit determination.
Education
Business Management - General Business, Medical Terminology/Coding
Draughn Business College
Joplin, MO05-1989
High School Diploma -
Webb City High School
Webb City, MO05-1988
Skills
- Proficient in Microsoft Word, Excel, PowerPoint, Microsoft Teams
- Accurate balance of monthly, quarterly, and annual financial reports
- Highly knowledgeable with ICD-9/10, CPT/HCPCS, Coordination of Benefits (COB), PPO Contracts, Plan Documents, ERISA, Reinsurance Contracts, Pharmacy Benefit Manager (PBM) Contracts
- Knowledge of ACA
- Licensed Producer in Health, Accident, and Life
- Notary
- Effective leader
- Problem-solving abilities
- Multitasking
- Reliability
- Team building
- Professionalism
- Time management abilities
- Project Management
Timeline
Director of Operations
Concierge Third Party Administrators
05.2017 - 10.2024
Client Service Representative
HealthSmart
10.2012 - 05.2017
Director of Operations
Mutual Assurance Administrators, BMI-HealthPlans
08.2007 - 10.2012
Claims Manager
BMI-HealthPlans
07.1997 - 08.2007
Claims Processor
BMI-HealthPlans
05.1988 - 07.1997
Business Management - General Business, Medical Terminology/Coding
Draughn Business College
High School Diploma -
Webb City High School
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