Cassandra Stansberry
Queen Creek,Arizona
Summary
Results-driven and technically-savvy Operations Director with a progressive career in private health insurance and Medicaid managed care sectors. Proven track record of turning around under-performing departments by delivering continuous process improvements to drive quality and efficiency. Motivating and respectful leader known for building and managing loyal, high-performance teams. Offering excellent communication, interpersonal and decision-making skills. Thriving in high-pressure environments. Expert in gathering, analyzing & defining business & functional requirements. Proven abilities in data-modeling, process-mapping, designing & re-engineering operational and technical processes.
Overview
21
21
years of professional experience
1
1
Certification
Work History
Encounter Operations Director
Evolent Health
06.2021 - Current
- Responsible for data and technical services and processes in the oversight of compliance for encounter metrics
- Responsible for the strategic plans for encounter metric improvements.
- Interfaces with internal and external customers on all issues that impact the encounters metrics
- Initiated cross-functional team collaboration to address gaps and deficiencies in configuration and claims adjudication that negatively impact encounter performance.
- Evaluates upstream and downstream processes to identify efficiency opportunities and possible gaps that may negatively impact encounter service level agreements
- Ensures timely and accurate updating of documentation related to all aspects of the encounters workstream.
- Proactively identified potential risks and implemented mitigation strategies to minimize negative impacts on projects or business operations.
Claims Administration Director
TriWest Healthcare Alliance
12.2019 - 06.2021
- Responsible for claims quality auditing, provider recoupment, provider reconsiderations (appeals), claims invoicing, provider claims issue resolution, and claims data reporting teams
- Responsible for ensuring that claims adjudication is compliant with Veterans’ Administration contract requirements
- Developed high-performing teams by mentoring, teaching, and giving team members opportunities for professional growth.
- Responsible for ensuring that claims related Veterans’ Administration contractual metrics are met
- Ensures that provider disputes regarding denials, pricing/reimbursement, and rejections are addressed timely and accurately
- Worked collaboratively with senior leadership to guide operational strategy.
- Responsible for the day-to-day oversight of the claims operations, claims payer vendor management and Veterans’ Administration Invoicing staff.
Provider Data Management Manager
Optum Health
06.2019 - 12.2019
- Oversee the credentialing and re-credentialing of all physicians, mid-level practitioners and organizational providers according to the plan specifications for multiple business units
- Oversee the provider setup processes ensuring accurately and timely setup for claims payment, member assignment and directory display
- Collaborate with the health plans and various departments on network expansion efforts, large claims and contract amendment projects and various related initiatives
- Identify process improvement opportunities to decrease cost, improve quality and increase efficiency within the department
- Review and update departmental policies and procedures to ensure compliance with NCQA, CMS and other regulatory agencies
- Monitor Medicare sanctioning reports to ensure compliance with Health Care Financing Administration (HCFA) requirements regarding prohibition of excluded provider participation
- Oversee the processing of claims for provider related pend reasons.
- Maximized department performance by monitoring daily activities and mentoring team members.
- Cross-trained existing employees to maximize team agility and performance.
Data & Technical Services Director
AmeriHealth Caritas
06.2017 - 06.2019
- Manages provider data activities for the local plans Medicaid network
- Provider data activities included data mining provider databases to identify data inaccuracies, triage, and opportunities for the creation of efficiencies; submission of, requirements identification, oversight of and approval of testing activities related to provider data related projects; collaborates with corporate IS to meet said activities
- Responsible for the oversight of all file transfers between the plan and its external customers (vendors, the state of Louisiana, and its' vendors)
- Managed encounter data submissions to the state’s Medicaid fiscal intermediary
- Responsible for triage and remediation of all data issues that impact this process
- This includes collaborating with the state’s Medicaid staff and with Amerihealth corporate IS staff
- Manages core claims adjudication system configuration changes for the plan
- Responsible for the identification and analysis of issues, organization of tasks associated with configuration activities, creating business requirements, approving test approaches, reviewing test data and implementation of changes
- Cultivated a positive work environment that fostered employee engagement, increased retention rates, and boosted overall team morale.
- Responsible for documenting provider notices related to system changes that impact the plan’s network of providers
- Supports implementation of systems, data, and technical requirements for oncoming plans
- Ensures compliance with the plan’s contractual requirements with the state
- Attests to the quality of the data submitted to the state.
- Strengthened internal controls by reviewing existing policies and procedures, ensuring compliance with regulatory requirements.
- Facilitated cross-functional collaboration for improved decision-making processes within the organization.
- Implemented innovative solutions to solve complex problems, resulting in increased productivity and streamlined operations.
MMIS Quality Assurance Manager
Molina Healthcare
12.2013 - 06.2017
- Manage the quality assurance and quality control activities of the QA testing staff
- Coordinate testing requirements and plans with the Louisiana Medical State staff in preparation for and in support of all levels of testing
- Perform formal and informal walkthrough sessions related to requirements, design, and coding to identify errors
- Maintain, report, and monitor all QA and QC activities via a database I created to track team activities
- Maintain and monitor all MMIS QA/QC development, maintenance, and quality assurance activities with all web-based software, operating systems, production control, and associated hardware and connections to mitigate risk and ensure continuity
- Maintain, monitor, and report documentation related to all activities of the technical writer staff
- Trained team members on quality assurance principles, fostering a culture of accountability and high performance.
- Those activities included assessment, updating, and creating content for the Louisiana/Molina shared intranet site, the Louisiana Medicaid site, internal system documentation
- Responsible for modifications and additions to ClaimCheck.
- Reduced defects in products by conducting thorough inspections and identifying areas for improvement.
System Application Manager
Blue Cross Blue Shield Of Louisiana
08.2007 - 11.2013
- Provide leadership to team by fostering and promoting configuring excellence, quality in the deliverables, process efficiency and innovation for the delivery of the configuration of business rules in the core administration system
- Provide timely and accurate technical support to the Operations areas within the organization by meeting established service level agreements through consistent partnering with Operations, Information Technology teams, and vendor technical support
- Provide operational support in the establishment and documentation of consistent and repeatable processes
- Develops and manages highly reliable and tested solutions
- Provides senior management and accountability for achieving and maintaining compliance with all regulations (Federal, State, and Blue Cross Association)
- Provides senior management and accountability for compliance with and adherence to SAS70 and Model Audit rules
- Improved application performance by identifying and resolving technical issues through regular system monitoring and maintenance.
- Provided comprehensive training materials for end-users, promoting smooth adoption of new technologies and systems.
- Championed change initiatives within the organization by advocating for Application Management best practices that improve operational efficiency.
Operations Manager
Blue Cross Blue Shield Of Louisiana
07.2003 - 08.2007
- Responsible for all management activities for mailroom operations, frontend claims editing (paper & electronic), Facets claims adjudication editing, and Facets claims adjustments processes
- Explore and develop innovative resources, goals, and programs for the expansion and efficient operation of the claims processing department
- Ensures that the educational, training and documentation needs of all staff are appropriate to meet daily and weekly goals
- Coordinates all communications on both internal and external issues in order to maintain provider and customer satisfaction; including facilitating all steps involved in the resolution of complex or special cases
- Accountable for leadership in personnel administration; including, but not limited to, motivation and training, in order to ensure departmental, divisional and corporate teamwork
- Responsible for individual and unit goal setting while determining staff needs based on inventory and available resources
- Accountable for compiling data and report generation for the purpose of analyzing and managing inventory, quality assurance and timeliness
- Manages budget through control of supplies and review of variances to ensure corporate cost goals are met
- Responsible for system analysis: problem identification, change design and implementation of new procedures and/or processes; testing, training, and follow-up on all implementations
- Provides technical assistance for divisional and interdivisional areas
- Interfaces with internal and external clients to promote high level of customer service.
- Supervised operations staff and kept employees compliant with company policies and procedures.
- Empowered employees to take ownership of their responsibilities, leading to increased accountability and improved performance outcomes.
- Conducted regular performance reviews, identifying areas for improvement and developing action plans to address them.
- Managed inventory operations to achieve timely and accurate delivery of goods and services.
- Led hiring, onboarding and training of new hires to fulfill business requirements.
- Developed systems and procedures to improve operational quality and team efficiency.
- Analyzed and reported on key performance metrics to senior management.
Education
Master Business Administration - Human Resource Management
Baker College
Flint, MI01.2004
Bachelor of Science - Business Management
University of Phoenix
Baton Rouge, LA01.2002
Skills
- Six Sigma Green Belt
- Systems Administration & Support
- Technology Planning
- Data/Business/Systems Analysis
- Data Flow & Process Mapping
- Queries & Data Modeling
- Major Software Implementations
- Disaster Recovery Planning
- Testing/Documentation
- Trizetto Facets Expertise
- Technical Writing (Manuals/System Specs)
- Operational Excellence
- Staff Management
- Staff Training and Development
- Allocating resources
- Overseeing training
- Business process reengineering
- Maintaining inventory
- Process Improvement
- Performance Improvements
- Teamwork and Collaboration
- Data Management
- Data Analysis
Certification
Six Sigma Green Belt
Timeline
Encounter Operations Director
Evolent Health
06.2021 - Current
Claims Administration Director
TriWest Healthcare Alliance
12.2019 - 06.2021
Provider Data Management Manager
Optum Health
06.2019 - 12.2019
Data & Technical Services Director
AmeriHealth Caritas
06.2017 - 06.2019
MMIS Quality Assurance Manager
Molina Healthcare
12.2013 - 06.2017
System Application Manager
Blue Cross Blue Shield Of Louisiana
08.2007 - 11.2013
Operations Manager
Blue Cross Blue Shield Of Louisiana
07.2003 - 08.2007
Master Business Administration - Human Resource Management
Baker College
Bachelor of Science - Business Management
University of Phoenix
Similar Profiles
Johnny Ferrell IIIJohnny Ferrell III
Appeals and Grievances Coordinator at Evolent HealthAppeals and Grievances Coordinator at Evolent Health
Kimberly Kelly-BuddKimberly Kelly-Budd
Utilization Review Nurse at Evolent HealthUtilization Review Nurse at Evolent Health
Manvendra Pratap SinghManvendra Pratap Singh
Senior Data Analyst at Evolent HealthSenior Data Analyst at Evolent Health
Jaylah ParrishJaylah Parrish
Coordinator, UM Intake at Evolent HealthCoordinator, UM Intake at Evolent Health
Diana TaceyDiana Tacey
Sales Associate at Club Demo ServicesSales Associate at Club Demo Services