Juliet Hopkins
Lakeland,FL
Summary
Dynamic professional with extensive experience in business operations and regulatory compliance. Proven track record in leading teams to optimize auditing processes and enhance operational efficiency. Committed to fostering a supportive environment while driving key initiatives that align with organizational goals.
Overview
14
14
years of professional experience
Work History
Team Lead Auditing Medicare & Medicaid Appeals
Healthfirst Insurance
07.2019 - Current
- Supervised eleven auditors and two senior auditors, ensuring compliance with Medicare and Medicaid quality audits.
- Facilitated team meetings to align staff with updated processes and directives. Identified non-productive projects and initiatives for reassessment.
Cultivated a supportive and positive work environment through targeted efforts. - Refined training method through strategic process improvements, leading to increased knowledge retention and enhanced production time using a phased training framework.
- Collaborated with senior management to optimize auditing processes, boosting team performance.
- Achieved recognition for maintaining lowest operational costs associated with overturns, rebuttals, spot check and compliance findings.
Enhanced auditing efficiency through strategic process improvements, resulting in measurable gains. - Evaluated employee skills regularly, providing coaching to boost accuracy and productivity.
- Oversaw onboarding and training activities, creating and updating job aids and training materials.
- Recommended actionable process enhancements and ensured follow-up for successful implementation.
- Engaged with senior managers to address performance trends and support strategic initiatives.
Medical Underwriter
United HealthCare
08.2018 - 01.2019
- Primary function was to gather information needed to support risk assessment process to analyze individual's insurability and determine appropriate course of action based on variables presented. Averaged 17 - 20 applications each day.
- Assessed eligibility for products or plans by reviewing applicant medical history, conducting telephone interviews, and analyzing prior claims, pharmacy profiles, and MIB data to identify potential risks.
- Negotiated coverage terms and conditions with clients, focusing on maximizing profitability while ensuring appropriate risk management.
- Reviewed existing policies and procedures, evaluated new underwriting practices, and identified improvements to enhance cost efficiency and align with organizational goals.
Senior Grievance & Appeal Administrator
Kaiser Permanente
12.2012 - 01.2018
- Effectively managed and resolved a heavy volume of complex, highly regulated complaints, grievances, and appeals in compliance with state and federal regulations and internal policies, verbally or in writing within designated regulatory time frames.
- Prepared comprehensive case summaries for inquiries from CMS, OPM, and Division of Insurance, and addressed formal inquiries from attorneys, government officials, brokers, and network providers.
- Attended legal hearings and provided testimony, representing department in legal proceedings regarding high-profile grievances and appeal determinations.
- Drove operations success by actively analyzing and reporting contractual or administrative deficiencies and trends to increase member retention by 25% annually.
- Developed training materials for staff that improved understanding of compliance procedures and supported operational effectiveness.
- Supported physicians and clinical staff in managing patients with behavioral issues and noncompliance.
Education
MBA - Healthcare Management - Health Administration
Marylhurst University
Lake Oswego, OR01-2016
BBA – Business Management - Business Administration And Management
American InterContinental University
Schaumburg, IL01-2011
Skills
- Medicare/Medicaid expertise
- Audit management
- Compliance expertise
- Risk assessment
- Claims recoupment
- EMR systems knowledge
- Microsoft Office suite
- Research and investigation
- Medical coding expertise
- Leadership skills
- Written and verbal communication
Timeline
Team Lead Auditing Medicare & Medicaid Appeals
Healthfirst Insurance
07.2019 - Current
Medical Underwriter
United HealthCare
08.2018 - 01.2019
Senior Grievance & Appeal Administrator
Kaiser Permanente
12.2012 - 01.2018
MBA - Healthcare Management - Health Administration
Marylhurst University
BBA – Business Management - Business Administration And Management
American InterContinental University