Carol Sutton
Plainfield,NJ
Summary
Experienced Claims Operations Manager with broad-based areas of expertise in overseeing claims processing, optimizing workflows, and leading cross-functional teams in a fast-paced environment. Proven track record in enhancing operational efficiency, reducing costs, and improving customer satisfaction. I am skilled in claims management, process improvements, team leadership, and data-driven decision-making. Adept at navigating complex claims systems, ensuring compliance with industry standards, and driving continuous improvement initiatives. Skilled Claims Operations Manager with proven experience in overseeing claims processes, developing operational strategies, and leading team performance. Strong in fostering efficient workflows, managing resources, and maintaining compliance with industry regulations. Effectively improved overall operations through strategic planning and problem-solving abilities. Possess strong communication skills, keen analytical acumen, and a commitment to achieving company objectives.
Overview
17
17
years of professional experience
Work History
Claims Vendor Manager
Healthfirst
New York, NY
12.2023 - 02.2025
- Mobilized and motivated, a high-performing team accountable for the end-to-end management of two external vendors; accountable for a combined staff of approximately 400 claims examiners and management team members
- Managed vendor relationships with a strong focus on optimizing procurement strategies and contract negotiations to achieve cost efficiencies and enhanced service delivery at Healthfirst
- Developed comprehensive vendor evaluation processes to assess performance and compliance with regulatory standards
- Initiated and led cross-functional collaboration to align vendor capabilities with organizational goals
- Directed analysis of vendor data to identify trends, uncover issues, and implement solutions that improved operational efficiency
- Facilitated regular performance reviews and feedback sessions with vendors, ensuring transparent communication and fostering partnerships grounded in mutual success
- Prepared detailed reports for senior leadership, presenting insights and recommendations to drive strategic decision-making within the vendor management framework
- Negotiated performance-based contracts and agreements to secure favorable terms and conditions, resulting in 18% cost savings and reducing turnaround time (TAT) by 8 days
- Built an ongoing partnership with Workforce Planning to ascertain optimal claim processing staffing by coordinating with the Data Analytics Leadership team to ensure proper execution of varying ramp plans; this partnership directly improved service level performance in late 2024 and early 2025
- Transitioned 1 billion dollars' worth of claims processing to third-party vendors
Claims Operations Manager
Healthfirst
New York, USA
01.2014 - 12.2023
- Provided strong leadership and guidance to diverse and geographically dispersed staff of Team Leads, Claims Examiners, and Business Analysts in the delivery of quality service
- Led the claims operations, ensuring efficient and accurate claims processing while maintaining compliance with regulatory standards
- Implemented process improvements to enhance workflow efficiency, reducing processing time and error rates
- Developed and maintained strong relationships with internal departments and external partners, facilitating effective communication and collaboration
- Managed the analysis of claims data to identify trends and implement strategic solutions that maximized operational effectiveness
- Provided training and mentorship to foster professional growth and increase departmental expertise
- Conducted regular audits of claims procedures and systems to ensure quality and reliability
- Developed comprehensive reports for senior management, highlighting performance metrics and recommending improvements to ensure the achievement of organizational goals
- Redesigned curriculum and testing for Claim Processing and Vendor Training
- Onboarded onshore and offshore vendors, resulting in approximately 300 claims examiners and management team members
- Restructured workforce alignment for cross-functional end-to-end processing, resulting in career pathing and extending staff retention by 2 years
- Implemented Incentive Program increasing performance by 20% while reducing yearly payouts by 100K
- Utilized statistical reports and keen analytical skills to make sound business and operational decisions that supported the divisional objectives, which resulted in improving TAT from 50+ days to 21 and KPI achieved
Operations Manager
Horizon Blue Cross Blue Shield of NJ
Newark, USA
01.2010 - 01.2014
- Streamlined team of up to 45 people with daily evaluations, coaching and mentoring to enhance staff performance levels for quality, production, and attendance while ensuring accuracy and compliance with internal/ external policies
- Managed all aspects of staff management in coordination with bargaining unions, management, and the organization
- Allocated work assignments to ensure daily receipts are processed per Service Level Agreements (SLAs)
- Evaluate data and create reports of daily receipts
- Monitor and track expenses to align with the defined budget
- Ensure customer satisfaction by developing business partnerships with internal and external customers for seamless results and by expediting resolutions of complex problems either by resolution or escalation
- Health Claims Authorization Processing and Payment Act (HCAPPA) implementation, interpretation and training of HCAPPA Mandate including claim processing and appeals
- Developing workflows, system updates, streamlining and process improvements
- Capitated/Fee for Service Claim Transition Claim System Conversion
Manager Executive Complaints and Appeals
Horizon Blue Cross Blue Shield of NJ
Newark, USA
01.2008 - 01.2010
- Managed the handling of high-level disputes efficiently, guaranteeing alignment with organizational protocols and governing regulations.
- Managed Level I and Level II Appeals and Claims associated with Health Claims Authorization Processing and Payment Act (HCAPPA)
- Strategic planning and tactical implementation of several system enhancements to increase reporting and work distribution automation
- Spearheaded the development of strategic procedures to enhance complaint management efficiency, improving customer satisfaction and trust
- Collaborated extensively with cross-functional teams to identify root causes and implement corrective actions
- Analyzed trends in appeals to generate insights and recommendations, fostering a culture of continuous improvement in service delivery
- Led training initiatives for staff to enhance their understanding of complaint-handling processes and maintain a high quality of service
- Maintained comprehensive records and reports for senior management, providing valuable data-driven insights for decision-making
- Reduced inventory of complaints from 15,000 to 600 within seven months
- Led the department to exceed the first-pass claim processing goal of 90% in 14 days and 99% in 30 days
- Exceeded HCAPPA goals of 98% resolved within 30 days
- Collaboration in the implementation of the Telecommuter Program for employees
Education
Bachelor of Arts - Business Administration
UNIVERSITY OF PHOENIX
Phoenix, AZ, USA01.2026
Skills
- Claims Management
- Administration
- Operational Efficiency
- Workflow Optimization
- Process Improvement
- Lean Methodology
- Team Leadership
- Staff Development
- Risk Management
- Compliance
- Data Analysis
- Reporting
- Claims Software
- Budget Management
- Cost control
- Customer Service Excellence
- Vendor Relations
- Negotiation
- Quality Assurance
- Auditing
- Cross-functional Collaboration
Professional Development
Trailblazer ASCENT, Harvard Business Corporate Learning, 2019
Accomplishments
- Negotiated performance-based contracts and agreements to secure favorable terms and conditions, resulting in 18% cost savings and reducing turnaround time (TAT) by 8 days
- Built an ongoing partnership with Workforce Planning to ascertain optimal claim processing staffing by coordinating with the Data Analytics Leadership team to ensure proper execution of varying ramp plans; this partnership directly improved service level performance in late 2024 and early 2025
- Transitioned 1 billion dollars' worth of claims processing to third-party vendors
- Restructured workforce alignment for cross-functional end-to-end processing, resulting in career pathing and extending staff retention by 2 years
- Implemented Incentive Program increasing performance by 20% while reducing yearly payouts by 100K
- Utilized statistical reports and keen analytical skills to make sound business and operational decisions that supported the divisional objectives, which resulted in improving TAT from 50+ days to 21 and KPI achieved
- Implementation of Health Claims Authorization Processing and Payment Act (HCAPPA) interpretation and training of HCAPPA Mandate including claim processing and appealsI
- Capitated/Fee for Service Claim Transition Claim System Conversion
- Reduced inventory of complaints from 15,000 to 600 within seven months
- Led the department to exceed the first-pass claim processing goal of 90% in 14 days and 99% in 30 days
- Exceeded HCAPPA goals of 98% resolved within 30 days
Timeline
Claims Vendor Manager
Healthfirst
12.2023 - 02.2025
Claims Operations Manager
Healthfirst
01.2014 - 12.2023
Operations Manager
Horizon Blue Cross Blue Shield of NJ
01.2010 - 01.2014
Manager Executive Complaints and Appeals
Horizon Blue Cross Blue Shield of NJ
01.2008 - 01.2010
Bachelor of Arts - Business Administration
UNIVERSITY OF PHOENIX
Similar Profiles
LUKE CORYLUKE CORY
Clinical Correspondence Writer/Editor at HealthfirstClinical Correspondence Writer/Editor at Healthfirst
Alexandria OliverAlexandria Oliver
Office Coordinator at HealthfirstOffice Coordinator at Healthfirst
Donna LebaronDonna Lebaron
Patient Sitter/observer at HealthFirstPatient Sitter/observer at HealthFirst