ERIC MEANS
Englewood,Ohio
Summary
Focus on continuous improvement for healthcare organizations. Align processes with business conditions, document impact of change and suggest policy revisions. Consultative approach to customer support. Effectively communicate with internal departments and senior leadership to gather and evaluate information and reconcile conflicts.
Overview
20
20
years of professional experience
1
1
Certification
Work History
OPERATIONS REGULATORY OVERSIGHT SPECIALIST II
12.2024 - Current
- Represent operations on cross-functional project work teams
- Submit, monitor and prioritize IT tickets for the operations departments
- Review special projects and identify issue trends and potential resolutions
- Assist with reporting and processes that are regulatory related and tied to state issues deadlines
- Assist with the development, drafting and review of P&P’s and job aids for Operations
- Assist in educating/training Business Partners on operations functions.
- Research and resolve provider claim issues and escalations by analyzing system configuration, payment policy, and claims data when requested by Compliance
- Perform analysis of all claims data to provide decision support to Claims management team in relation to regulatory requests
- Identify and quantify data issues within Claims and assist in the development of plans to resolve data issues
- Partner and collaborate with Operations Business Owners to ensure all audit and regulatory deliverables are met accurately and on time. These deliverables may include:
- Documentation gathering – i.e. review of Standard Operating Procedure and/or Policy and Procedure to the audit/inquiry requirements
- Audit Universe monitoring and/or creation – collaboration with IT and the Business Owners to validate the accuracy of the data and formatting of the final report for submission
- Prepare Operations Business Owners for live questions and answers with the state regulators or auditors
- Track and assist with remediation efforts for Corrective Action Plans related to all audit findings
- Ensure the timeliness submission of the Regulatory Reporting required by the state and federal agencies for Operations
- Track all Compliance required training on a yearly and new hire basis for Operations
- Assist with all readiness activities in relation to implementation of a new line of business for Operations
UTILIZATION MANAGEMENT SPECIALIST TEAM LEAD-CUSTOMER CARE
CARESOURCE
06.2022 - 01.2024
- Transitioned 17 UM Specialist to the Service Center from the Utilization Management Department where I managed the staff’s calls and Metrics like adherence, average handle time from a UM Intake perspective.
- Audited team performance and developed improvements for internal processes by using call monitoring soft like Quality Central as well as create RBCs (Rule Based Classifiers) using the Authentix Artificial Intelligence system.
- Prepared process maps, pivot tables using Excel, SIPOC charts and process maps using Vizio, PowerPoint, and Word to improve the team’s adherence metric.
- Collaborated with internal business partners such as Provider information management, clinical care nurses, medical directors and grievance and appeals which resulted in an open line of communication for any external or internal changes that have been made.
- Experienced with systems such as Facets, Power BI, Guiding Care, D365 (CRM) to manage the staff’s Provider Services and Utilization Management call types.
ENROLLMENT SPECIALIST II
CARESOURCE
10.2019 - 06.2022
- Process enrollment files according to appropriate regulatory guidelines working out of Microsoft Access using SQL Database to work with the Data.
- Completion of daily change file pre-processor exceptions and monthly full file pre-processor exceptions
- Research member eligibility and take appropriate actions to resolve issues across all eligibility systems.
- Process mass Primary Care Physician (PCP) changes with Provider Operations
- Research, review, and interpret eligibility data to respond to eligibility inquiries from contracted vendors.
- Access state and federal government systems to review and confirm eligibility status.
- Complete all required corporate training within stated timelines to a satisfactory manner.
CLAIMS MANAGER GBD CLAIMS
ANTHEM INC
01.2018 - 05.2019
- Managed Claims Inventory to ensure claims are processed by our claim’s specialist according to their SLAs.
- Managed sixty claims analyst in Tampa, Miami, Virginia Beach, Texas, and California both working at home and in the office.
- Was successful with bringing a total of 196,000 claims that were out of compliance for missing the adjudication turnaround SLA down to 12,000 and an average of 7-day turnaround time by working with operations analyst to include claims that could be processed by Marcos.
CUSTOMER SERVICE TEAM LEAD
COGNIZANT
09.2016 - 01.2018
- Managed a staff of 16-20 advocates addressing members’ inquiries regarding their benefits, cost sharing, and claims processing for our Medicare, Medicaid, Commercial and the Affordable Care Act Marketplace members.
- Created and managed the inventory process of the corporate escalations, legislative complaints, and social media complaints received from the Tampa FL, Cebu Philippines, and Manila Philippines.
- Conducted reporting and auditing using Facets and creating pivot tables using excel to present updates to client to show progress as well as improvement to processes and procedures.
- Conducted auditing and coaching for staff calls on a weekly basis to ensure accuracy.
MEDICAL PAY REP
Progressive Insurance
05.2015 - 09.2016
- Medical Pay Rep is responsible for analysis and adjustment of moderately complex medical claims.
- Interprets medical records and understands medical terminology regarding injuries.
- Reads/conducts research to better understand medical records and establish any correlation to a motor vehicle accident could also research injuries or medical conditions.
- Injury causation may involve following up with a provider and/or securing medical records and recognizing the need for an IME/IMR.
CUSTOMER SERVICE/MARKETPLACE INSURANCE SPECIALIST TEAM LEAD
CARESOURCE
02.2012 - 01.2015
- Managed 13 to 25 employees and allocation of resources.
- Consumer Sales & Services Representative and Marketplace.
- Transitioned team from call takers to professional group able to manage complex situations, maintain 97% average quality rating, consistently meet schedules, and enhance personal growth through greater visibility within company.
CALL CENTER TRAINER
INFOCISON
11.2005 - 12.2006
- Call Center Trainer for 15-25 people during orientation and 90-day trial period before assignment to permanent teams.
- Also trained existing employees on new products and managed graduations, extensions of training, and terminations.
- Received Excellence Award for performance.
Education
Six Sigma Green Belt Certification -
Caresource
06-2024
Computer Science and Healthcare
Sinclair Community College
01-2008
High School Diploma - undefined
Dayton Christian
Dayton, Ohio06-2003
Skills
- Project Management
- Auditing & Reporting
- Microsoft Excel, Word, Vizio
- Process Improvement
- Work Independently & Team
- Database Management
- Workflow Planning & Control
- Facets and SQL Database Systems
- Collaborative Claims Management
Certification
Lean Six Sigma Green Belt
Timeline
OPERATIONS REGULATORY OVERSIGHT SPECIALIST II
12.2024 - Current
UTILIZATION MANAGEMENT SPECIALIST TEAM LEAD-CUSTOMER CARE
CARESOURCE
06.2022 - 01.2024
ENROLLMENT SPECIALIST II
CARESOURCE
10.2019 - 06.2022
CLAIMS MANAGER GBD CLAIMS
ANTHEM INC
01.2018 - 05.2019
CUSTOMER SERVICE TEAM LEAD
COGNIZANT
09.2016 - 01.2018
MEDICAL PAY REP
Progressive Insurance
05.2015 - 09.2016
CUSTOMER SERVICE/MARKETPLACE INSURANCE SPECIALIST TEAM LEAD
CARESOURCE
02.2012 - 01.2015
CALL CENTER TRAINER
INFOCISON
11.2005 - 12.2006
Computer Science and Healthcare
Sinclair Community College
High School Diploma - undefined
Dayton Christian
Six Sigma Green Belt Certification -
Caresource