Jessica Heath
Overview
14
14
years of professional experience
Work History
CLAIMS MANAGER
TEXAS CHILDREN'S HEALTH PLAN
06.2024 - Current
- Responsible for managing the day-to-day activities of the project team staff and claim educator auditor staff
- Responsible for reporting monthly employee and claim adjudication quality audit results
- Implementation of fundamental claims training for staff
- Implementation on reoccurring focus audits to identify trends that require remediation
- Conducts comprehensive analysis of claim error trends to develop action plans, system enhancements and performance improvement plans for staff
- Responsible for project planning and overseeing activities related to implementation of new regulatory requirements and claim rules
- Responsible for overseeing the development of claims training and standard operating procedures
- Responsible for intake of claims related MCO notices to determine if action is required
- Coordinates with subcontractors on overseeing payment integrity activities
- Perform root cause analysis on claim escalated issues/complaints to develop performance improvement plans on trends identified
- Responsible for overseeing state complaints related to claim issues
- Collaborate with internal business partners to understand operational deficiencies and implement best practices.
CLAIMS DIRECTOR
TEXAS CHILDREN'S HEALTH PLAN
07.2023 - 05.2024
- Oversee all aspects of claim operations supporting a staff of 81 employees
- Responsible for the daily and overall operations of claims adjudication, intake, projects, adjustments, refunds, and claim appeals
- Improved the CRM service level agreement by 30% in 60 days
- Sustained 100% compliance with claim and appeal timeliness standards
- Decreased appeal receipts from 9% to 4% through Tapestry system updates
- Improved claim auto adjudication rate by implementing new claim rules post Tapestry system implementation
- Successful decommission of QNXT claim system
- Improved teams quality performance by developing role based train to optimize employee performance
- Responsible for overseeing all quality procedures and training initiatives
- Developed capacity plan for claim operations
- Implementation of day-to-day processes and goal setting for all functional areas
- Development, review and implementation of departmental policies and procedures to ensure compliance
- Management of claim inventory to include action plans and change opportunities
- Establishes goals and objectives for the functional teams, based on the needs of the organization and regulatory requirements
- Effectively collaborates with internal and external stakeholders to support organization goals
- Responsible for overseeing claims metrics and processes to ensure compliance with regulatory required standards and guidelines.
CLAIMS ASSISTANT DIRECTOR
TEXAS CHILDREN'S HEALTH PLAN
07.2019 - 07.2023
- Responsible for the coordination of all operational management activities related to claims processing
- Decreased claim inventory by 30% by implementing system changes to increase efficiencies
- Responsible for overseeing claims inventory and aging includes those in other areas through a collaborative approach to ensure timely payment
- Collaborates across departments, devising and refining processes, which improved claim processing outcomes
- Facilitate daily claims work groups to resolve complex and critical claims issues
- Ensure accurate and timely implementation and maintenance of critical information on claims databases
- Conduct post-implementation oversight processes & workflows
- Collaborate with Project Managers to develop project tasks and durations related to requirement activities
- Serves as Business Owner of claim systems and partners with IT, identifying opportunities for improvements, creating enhancements, and improving efficiencies
- Ensure claims from providers and facilities are processed in compliance with federal and State regulations
- Interact with Information Technology department to develop regulatory reporting and system enhancements
- Provide status reports and project updates to management and stakeholders
- Develop, maintain and enforces production, turnaround and accuracy standards for the claims department.
CLAIMS MANAGER
TEXAS CHILDREN'S HEALTH PLAN
05.2017 - 07.2019
- Managed a staff of 19 specialists responsible for appeals and complaints
- Developed, maintained and enforced production, turnaround and accuracy standards
- Increased production by 50% first 90 days of employment
- Measured and completed reports on staff performance
- Monitored staff levels in relation to volume and allocates resources as needed
- Responsible for project planning and appeals inventory management
- Analyze appeal data to identify current trends, payment discrepancies, and provide impact to leadership
- Perform root cause analysis and participate in performance improvement projects based on trends identified
- Responsible for handling escalated issues which require a high degree of appropriate knowledge, research, and communications with stakeholders to achieve timely resolution
- Keep management abreast of developments within the operation and provide support to management on special projects
- Collaborate with internal business partners to improve cross-functional processes.
CLAIMS SUPERVISOR
TEXAS CHILDREN'S HEALTH PLAN
07.2016 - 05.2017
- Supervised a team of 12 examiners responsible for accurately processing claims within regulatory requirements
- Monitored claim inventory and assigned daily assignments and projects to staff
- Collaborated with internal departments to meet company goals
- Analyzed claim data to identify trends
- Ensured accurate payment of high dollar claims
- Facilitated meetings and trainings as needed
- Coached and counseled employees to meet and exceed quality, and productivity standards; removed obstacles preventing individuals from meeting goals
- Resolved escalated claims issues
- Served as a subject matter resource to team members, supervisors, and management staff
- Participated in the development of action plans and goals.
CLAIMS BENEFIT SPECIALIST
TEXAS CHILDREN'S HEALTH PLAN
03.2012 - 07.2016
- Resolved medical appeals by approving or denying documentation; calculating benefit due; initiating payment or composing denial letter
- Ensured legal compliance by following company policies, procedures, guidelines, as well as state and federal insurance regulations
- Maintained quality customer service by following customer service practices; responding to provider and member inquiries
- Researched and processed refunds from providers
- Analyzed claim data to identify current or emerging trends
- Reviewed appeals and determined the accuracy of payment or denial
- Prepared all documentation and processed refunds for offset requests for providers.
SUPERVISING AGENT
AMERICAN INCOME LIFE
01.2011 - 12.2011
- Supervised a team of 5 Sales agents
- Responsible for customizing insurance plans to suit individual customers
- Ensured that policy requirements were fulfilled, including any necessary medical examinations and the completion of appropriate forms
- Trained Agents
- Tracked sales and distributed advances.
Timeline
CLAIMS MANAGER
TEXAS CHILDREN'S HEALTH PLAN
06.2024 - Current
CLAIMS DIRECTOR
TEXAS CHILDREN'S HEALTH PLAN
07.2023 - 05.2024
CLAIMS ASSISTANT DIRECTOR
TEXAS CHILDREN'S HEALTH PLAN
07.2019 - 07.2023
CLAIMS MANAGER
TEXAS CHILDREN'S HEALTH PLAN
05.2017 - 07.2019
CLAIMS SUPERVISOR
TEXAS CHILDREN'S HEALTH PLAN
07.2016 - 05.2017
CLAIMS BENEFIT SPECIALIST
TEXAS CHILDREN'S HEALTH PLAN
03.2012 - 07.2016
SUPERVISING AGENT
AMERICAN INCOME LIFE
01.2011 - 12.2011