Dexter Thomas
Summary
Experienced Director of Claim Operations with a proven track record in integrating operational strategies, fostering partnerships, and nurturing team member growth. Adept at managing key performance indicators (KPIs) and implementing internal controls to monitor operational trends and devise innovative solutions. Results-oriented with adaptability and resilience in resolving challenges.
Overview
17
17
years of professional experience
Work History
Claims Director
UST Health proof
04.2022 - 02.2025
- Provide ongoing direction and guidance to multiple onshore and offshore teams direct and indirect reports
- Plan, implement and manage operations per the Statement of Work
- Handled claims consistent with client and corporate policies, procedures, best practices and regulations.
- Assist internal and external business partners with completion of tasks and remediation to achieve SLAs
- Support VP of Operations Strategic vision by prioritizing initiatives
- Monitor, Evaluate KPIs and other Operational Programs
- Collaborated with peers and internal departments to identify innovation opportunities
- Monitored team performance, enforcing compliance with corporate claims processes and procedures.
- Cultivated productive relationships with stakeholders, facilitating claims lifecycle.
- Championed insurance claims process by providing expert knowledge and building positive, trusting relationship to support clients during challenging times.
Manager II WGS COE Provider Disputes
Anthem Inc
10.2021 - 04.2022
- Oversight of Provider Disputes and Recon teams in California, West Virginia, South Carolina, and Intake teams
- Executed Strategy to resolve over 7K Provider Disputes that were out compliance by 12/22/21
- Innovated Strategy to bring Intake processes from 10 DOH to 1 Day on hand
- Innovated robust reporting strategy by working with Data Analytics
- Point of contact for streamlining WGS PDR team workflow within NextGen
- Proactively worked cross functionally to resolve escalated issues
Director of Claims
CareSource Management Group
09.2018 - 11.2020
- Director for all Non – Ohio Markets
- Those markets included Indiana, Georgia, Kentucky, and all of Marketplace
- (GA, IN, KY OH and WV)
- Reduction of claims pended inventory of 550K claims over 30 days to under 2% within 120 days
- All teams consistently meeting state prompt pay requirements from Jan 19 – Present
- Oversight of 4 Direct reports, over 80 indirect reports
- Collaborate with the state health plans on claims trending and state complaints
- Set operational SLA and standard timeliness requirements to meet state prompt payment guidelines for processing
- Claims point of contact for the Humana/CareSource transition of Kentucky Medicaid workgroup
- Ensure standard programs and training are in place to ensure consistent achievement of KPIs
- Regularly evaluate policies and procedures to ensure consistent application and effective operation
- Execute alternative strategies for improved effectiveness of claims operations
- Establish measures and processes by which to collect, monitor, evaluate, and report on key performance indicators
- Continually increase the use of data as a basis for making business decisions
- Create plans to develop claims associates and reinforce a positive work culture
- Take prompt and decisive corrective action when necessary to ensure achievement of financial, operational, quality and service goals for the department
- Evaluation of department readiness and staff preparedness for business evolution and expansion
- Provide direct reports with timely and constructive performance feedback
- Ensure cost center operating budget stays within operating margin
Director of Claims
Meridian Health Plan
02.2017 - 09.2018
- Oversight claims production that included OCR, Front End Production, Adjustments and Recoupment
- Claims oversight states included Michigan, Illinois and Lucas County, Ohio
- Directs Operational functional areas that include specialized business units for Claims Examiners, Quality/Audit, Recoupment, internal quality control and adjustments
- Oversight of 6 Direct reports, over 130 indirect reports
- Implement and maintain efficient claims adjudication process that effectively utilized technology to automate business processes and maximize the accuracy of claim payments
- Developed collaborative relationships with our internal customers and other stakeholders with a focus on enhancing the service provided to members
- Oversaw and ensured that Claims Operations had proper technology and operational systems
- Developed and maintained strong relationships with all key vendors that supported Claims Operations, while holding them accountable for delivering their contractual commitments
- Managed the Claims Operations' annual operating and capital budgets within industry standards and best practices to maintain an affordable and efficient cost structure
Manager Medicaid Claims Operations
Molina Healthcare Inc.
09.2015 - 02.2017
- Ensured claims were processed in accordance with timely filing guidelines to avoid interest payment penalties
- Responsible for maintaining all departmental policies and procedures, ensuring that they are reflective of the current processes to carry out day- to-day operations
- Collaborated with the state health plans and claims supervisors on various claims-related issues
- Oversight of 3 Direct reports and 60 indirect reports for states which included Washington, South Carolina, and Florida Marketplace
- Hire, train, retrain and maintain a qualified staff of exempt and non-exempt employees
- Coaching and developing skills of staff members and conducting performance evaluations
- Maximize human capital & growth potential
- Solid understanding of standard claims processing systems and claims data analysis
External Consultant: Medical Management Specialist
The Judge Group Inc.
04.2015 - 08.2015
- Gathered clinical information regarding specific cases and determined appropriate area to refer or assign cases (utilization management, case management, QI, Med Review)
- Provided network providers or general program information when requested
- Reviewed and assisted with complex cases
- Acted as a liaison between Medical Management and/or Operations and internal departments
- Responsible for conducting any utilization management review activities which require interpretation of clinical information
Manager Commercial Claims Operations
Humana, Inc.
04.2013 - 03.2014
- Responsible for maintaining all departmental policies and procedures, ensuring that they were reflective of the current processes to carry out day- to-day operations
- Oversight and collaboration with Business Consultants from offshore vendor claims processes
- Reviewed and analyzed processes of claim inventory and developed plan of actions weekly to ensure claims performance guarantees were accomplished
- Directly managed 6 supervisors with multiple teams with over 150 associates and 12 different claim processes
- Developed automated process script for a 50% reduction in ER claims within 1 month
- Hire, train, retrain and maintain a qualified staff of exempt and non-exempt employees
- This includes coaching and developing skills of staff members and conducting performance Evaluations
- Maximize human capital & growth potential
- Solid understanding of standard claims processing systems and claims data analysis
Medicare Claims Business Consultant
Humana, Inc.
09.2012 - 04.2013
- Assisted in creating business models and concepts to enhance the quality and consistency of acquired claim business
- Aligned the internal and external claims processes, procedures, people, and technology to meet ramp down, sunset deadlines
- Worked collaboratively across multiple onshore departments and functions
- Strong working relationships with Offshore vendors
- Created and maintained systems and processes for operating efficiency
- Developed claims acquisitions playbook/ guidelines for future company mergers and acquisitions
- Solid understanding of standard claims processing systems and claims data analysis
Medicare Claims Supervisor
Humana, Inc.
04.2008 - 09.2012
- Developed an excel spreadsheet for a 65% reduction in associates down time that lead to an increase in production by 5 more claims per hour
- Coached, mentored, and trained team leads, hired, retained, and developed talent
- Led, inspired, an engage associates to exceed department and unit expectations
- Created and maintained systems and processes for operating efficiency
- Supervised staff, ensuring performance standards were met through monitoring of productivity and quality reports
- Supervised 2 teams and 40 cross-functional associates
- Development of processes during transition from CCE platform to Web
- Strat software
- Leadership during the absence of the supervisor
- Leveraging associate's skill set to drive better quality and production
- Identified root causes, proposes solutions, and assesses outcomes for future learning
- Maintained high standards for quality and an exceptional consumer experience
- Actively coached the team on bringing quick resolution to a variety of business needs
- Created a positive work environment
- Point person and coaching mentor for lean training
- Development of knowledge base training for Medicare claims teams
- Subject matter expert within the Pro Perspective System area
- Solve complex system, product, or service problems through a collaborative working with leadership
- Outperform the competition and win through continuous upgrading of one's own and other's work performance
- Achieve results each quarter to earn incentives
- Proactively identifies and evaluates problems
- Identifies appropriate subject matter experts and other information resources to resolve problems
- Collects, analyzes, and draws conclusions from information
- Leverages appropriate problem-solving/analysis tools and/or steps
- Bailout Customer Service phones for Medicare and Pharmacy when in need of assistance
Education
Bachelor of Science - Business Administration And Management
Spalding University
Louisville, KY05-2010
Skills
- Transformational Leader
- Performance metrics analysis
- Team building and motivation
- Effective Leadership Abilities
- Performance Evaluation
- Claims auditing
- Quality assurance
- Claims processing
- Strategic Development
Timeline
Claims Director
UST Health proof
04.2022 - 02.2025
Manager II WGS COE Provider Disputes
Anthem Inc
10.2021 - 04.2022
Director of Claims
CareSource Management Group
09.2018 - 11.2020
Director of Claims
Meridian Health Plan
02.2017 - 09.2018
Manager Medicaid Claims Operations
Molina Healthcare Inc.
09.2015 - 02.2017
External Consultant: Medical Management Specialist
The Judge Group Inc.
04.2015 - 08.2015
Manager Commercial Claims Operations
Humana, Inc.
04.2013 - 03.2014
Medicare Claims Business Consultant
Humana, Inc.
09.2012 - 04.2013
Medicare Claims Supervisor
Humana, Inc.
04.2008 - 09.2012
Bachelor of Science - Business Administration And Management
Spalding University
Similar Profiles
Charise SimonCharise Simon
Customer Service Associate II at UST Health Proof/Clover HealthCustomer Service Associate II at UST Health Proof/Clover Health
Dhanisha SDhanisha S
Product Implementation Lead at UST -Project Clover HealthProduct Implementation Lead at UST -Project Clover Health
Sruthi SudhagaranSruthi Sudhagaran
Software Developer at UST Global (Client : Elevance Health)Software Developer at UST Global (Client : Elevance Health)