APRIL STEPHENS
Summary
Experienced healthcare professional with 17 years of experience of meeting Texas Medicaid and Managed Care and Children with Special Healthcare Needs Services programs while utilizing consistent and organized practices. Skilled in working under pressure and adapting to new situations and challenges to best enhance the brand. Background as a Medical Policy Support Supervisor and a Senior Research Project Analyst will offer collaborative teamwork and attention to detail experience to maintain full-time position that offers professional challenges utilizing interpersonal skills, excellent time management and problem-solving skills.
Overview
14
14
years of professional experience
Work History
Compliance & Reporting Specialist
Centene Corporation
03.2024 - 08.2024
- Develop and maintain quality and compliance reports and dashboards
- Review and analyze deliverables and data reports to ensure timeliness of submission and identify trends in performance and improvement opportunities
- Perform and monitor audits, risk assessments and documentation activities to ensure compliance
- Identify, investigate, and resolve compliance issues and develop corrective action plans to mitigate future risks
- Serve as the 'go to' person for all compliance activities including training and awareness programs
- Design, implement and improve regulatory documentation and processes to address compliance issues and concerns related to all federal and state regulatory requirements, contract requirements and company standards
- Research new markets and primary source verification to determine licensure requirements and administer ongoing licensure maintenance
- Assist with vendor activities, including documentation of all pre-and annual delegate oversight and on-going vendor oversight and partnership activities
- Update management on the status and activities pertaining to compliance, contract deliverables and related activities
Claims Specialist & Investigator
State Farm
09.2022 - 02.2024
- Investigating, evaluating, negotiating, and settling claims
- Applying knowledge of policies, procedures, laws, statutes, and insurance regulations when determining coverage, liability, & damages
- Analyze complex information from different sources
- Prepare and process claim reports
- Consult with specialists (i.e Physicians, medical resources)
- Calculate benefits and payments
- Settled complex claims with claimants and attorneys fairly by applying critical thinking, negotiation skills, and detailed knowledge of insurance policies
- Support company attorneys & defend company in case of contestation to include conflict resolutions and/or mediations
- Examine police reports, videos from surveillance cameras or audio when applicable
- Developed strong working relationships with external partners such as adjusters, legal counsel, and medical professionals to facilitate efficient claim resolution processes.
- Contacting customers via telephone, written correspondence and/or various electronic media
- Effectively managing work through task driven queues while multi-tasking in a fast-paced call center environment
- Supporting our customers through personalized, caring, and simple interactions
- Enhanced customer satisfaction with timely communication, empathy, and clear explanations of claim outcomes
- Managed a high volume of claims effectively by prioritizing tasks and maintaining excellent organizational skills
Medical Policy Support (MPS) Supervisor
Accenture/TMHP
09.2019 - 03.2022
- Manage and oversee a staff of 8 employees that consist of Sr Research Project Analyst, Clinical Liaison, Clinical Coders, Implementation analyst
- Applied strong leadership talents and problem-solving skills to maintain team efficiency and organize workflows.
- Coordinate and assist the state stakeholders of the Medical Policy Support Annual and Quarterly reviews of the International Classification of Disease (ICD) and HealthCare Common Procedure Coding System (HCPCS) process
- Oversee the coordination of the MPS Research Business Service Requests that are submitted from various internal areas that consist of researching provider inquiries and system updates
- Monitor and respond to Medicaid Contracts Administration Tracking System (MCATS) and State Action Request (SAR)
- Monitor the Legislative inquiries and impact surveys to determine medical policy impacts
- Ensure SharePoint medical policy document folders are created, monitored, and maintained for related medical policy updates
- Monitor technology system updates conducted through Demand Management Meetings that have medical policy impacts
- Ensure the monthly Medicaid and CSHCN Service Program medical policy implementation timelines were met
- Facilitate or attend the state stakeholders Benefit Assessment Meetings (BAM) for policy development
- Facilitate bi-weekly internal medical policy implementation meetings
- Serve as a liaison between operational staff, technical team, and State agencies
- Attend and provide medical policy updates during the bi-weekly state stakeholder Medical Policy Check-in meetings
- Attend internal/external operational meetings to include state stakeholders for various system enhancements, Legislative Sessions, State Medical Benefits Meetings
- Experience managing complex, cross-functional projects and strategic planning
- Research data, analyze and complete research/review of various projects requested by leadership
- Created and executed the Project and Portfolio Management (PPM) system enhancement to support the medical policy flow process
- Led projects and analyzed data to identify opportunities for improvement
- Exceeded goals through effective task prioritization and great work ethic
- Identified issues, analyzed information and provided solutions to issues
- Devoted special emphasis to punctuality and worked to maintain outstanding attendance record
- Prepared variety of different written communications, reports and documents
- Used critical thinking to break down problems, evaluate solutions and decision making
- Track and research related medical policy pre-analysis, Reference Data Maintenance (RDM), Document Research Team (DRT), fiscal/pricing unit, and application services Business Service Request (BSRs) with medical policy impact
Senior Research Project Analyst
Accenture/TMHP
09.2015 - 09.2019
- Perform monthly QA of the Medicaid/CSHCN medical policy implementations
- Monitor, research data and respond to Medicaid Contracts Administration Tracking System (MCATS) and State Action Request (SAR)
- Maintained Medical Policy Implementation and SAR spreadsheets
- Track and research related medical policy, Reference Data Maintenance (RDM), Document Research Team (DRT), pricing unit and application services Business Service Request (BSRs) with medical policy impact
- Provides expertise in the areas of operational requirements of medical policy deployment, while assisting in development
- Served as a liaison between operational staff, technical team, and state agencies
- Contributed to successful project outcomes by providing accurate forecasts and risk assessments.
- Attended bi-weekly Operations Implementation meetings
- Attended internal/external Operational meetings to include state stakeholders
- Attended bi-weekly Benefit Initiative Process (BIP) and CSHCN meetings
- Research data, analyze and complete research/review of various projects requested by leadership
Senior Category Analyst
Accenture/TMHP
09.2014 - 09.2015
- Liaison to research referrals and complaints received from the State and Legislative offices
- Responded to each request with clear and concise detailed documentation summarizing the research findings
- Monitor each case, which is date, time sensitive, and requires strong organization skills to manage the number of requests
- Collaborate with cross-functional teams to resolve issues timely while maintaining strong communication channels.
- Prepared various written communications, reports and documents for tracking to submit to the state stakeholders
- Maintained energy and enthusiasm in fast-paced environment
- Used coordination and planning skills to achieve results according to schedule
- Carried out day-to-day duties accurately and efficiently
Medical/Dental Policy Development Project Analyst
TMF/TMHP
01.2011 - 07.2014
- Perform monthly Q&A of the Medicaid/CSHCN medical policy implementations
- Monitor, research and respond to Medicaid Contracts Administration Tracking System (MCATS) and State Action Request (SAR)
- Assisted in the development of comprehensive project plans, setting realistic timelines and milestones.
- Collaborate with the medical policy nurse analyst on incoming SARs
- Maintain Medical Policy Implementation and SAR spreadsheets
- Provided monthly Medicaid/CSHCN policy implementation reporting to State Stakeholders
- Track and research related medical policy pre-analysis, RFT, DRT, fiscal/pricing unit, and application services Business Service Request (BSRs) with medical policy impact
- Served as a liaison between operational staff, technical team, and state agencies
- Perform/present Medicaid/CSHCN policy reporting at the bi-weekly Benefits Management Workgroup (BMW) Executive meetings
- Facilitated bi-weekly Medical Policy Operational Implementation meetings
- Attended bi-weekly Benefit Initiative Process (BIP) and CSHCN meetings
- Upon leadership request, researched, analyzed and completed various projects
Education
High School - Business of Computer Science
George Washington Preparatory Senior High School
Los Angeles, CA06-1977
Skills
- Teamwork and Collaboration
- Excellent Communication
- Attention to Detail
- Effective Decision-Making
- Multitasking
- Organization and Time Management
- Critical Thinking
- Supervisor Experience
- Progressive Teambuilding
- Microsoft Office Software Proficiency
- Client relationship building
- Fraud prevention
- Training and Development
- Successful Problem-Solving
Software
- Adobe Framework
- Encoder Pro
- Kintana
- Project and Portfolio Management (PPM) System
- Medicaid Contracts Administration Tracking System (MCATS)
- Phoenix Claims System
- SharePoint
- SIR2000
Timeline
Compliance & Reporting Specialist
Centene Corporation
03.2024 - 08.2024
Claims Specialist & Investigator
State Farm
09.2022 - 02.2024
Medical Policy Support (MPS) Supervisor
Accenture/TMHP
09.2019 - 03.2022
Senior Research Project Analyst
Accenture/TMHP
09.2015 - 09.2019
Senior Category Analyst
Accenture/TMHP
09.2014 - 09.2015
Medical/Dental Policy Development Project Analyst
TMF/TMHP
01.2011 - 07.2014
High School - Business of Computer Science
George Washington Preparatory Senior High School
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