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Kimberly Conley
Surprise,Arizona
Summary
20+ years in healthcare claims and audit operations. Leading teams with integrity and maintaining a proven record as a consumer centric leader. Results driven leader with a history of meeting and exceeding production metrics, quality, and internal service level agreements. Deep knowledge of Commercial, Medicaid, Medicare, and Indemnity product lines.
Medical claims processing
Skilled specialist with proven track record in delivering impactful results. Adept at team collaboration and flexible in adapting to changing needs. Expertise in medical claims processing, consistently driving successful outcomes. Known for reliability and strong focus on achieving objectives.
Knowledgeable Claims Quality Assurance Supervisor with solid foundation in specialized tasks and track record of delivering results through targeted initiatives. Proven ability to implement effective strategies that enhance operational efficiency and support team objectives. Demonstrated proficiency in problem-solving and project management.
Overview
41
41
years of professional experience
Work History
Workers Comp Specialist
Vensure Employer Solutions
06.2024 - Current
- Shadow adjusting and acting as a liaison between the injured worker, and TPA responsible for deciding workers' compensation losses
- Detailed claims analysis, accident and subrogation investigation identifying red flags and potential fraud
- Accurate reserving practices, facilitating light duty, oversight of both medical and legal management
- Ability to evaluate settlement value and coverage issues
- Mitigating claim severity and driving positive claim outcomes by leading our TPA towards claim resolution
- Preparing and presenting strategic claim reviews with client and/or carrier
- Improved customer satisfaction rates through proactive problem-solving and efficient complaint resolution.
- Collaborated with cross-functional teams to achieve project goals on time and within budget.
- Implemented new training programs for staff, leading to higher employee retention rates and better overall performance.
Claims Support Supervisor
TriWest Healthcare Alliance
09.2020 - 05.2024
- Supervise team of thirteen Claim Reviewers evaluate and analyze workflow, develop reporting, and policies and procedures for the department
- One on One meetings and performance appraisals
- Coaching and training development sessions with the team
- Provide timely and constructive performance feedback
- Efficient inventory management manages inventory within 15 days
- Supervise team of Claims Reviewers consisting of thirteen direct reports and ten indirect reports on the provider written correspondence team for provider reconsideration and appeals
- Exceeded production standards by reducing backlogged inventory from 50k down to 15k
- Perform root cause analysis on claim processing errors to improve quality and accuracy results
- Collaborate with internal departments to discuss audit findings, and trends monthly
- Implement process Improvements by way of training, coaching, and mentoring of team members
- Established clear performance expectations for the support team, resulting in improved accountability and measurable results.
- Analyzed performance metrics to identify areas for improvement and implement targeted strategies.
- Reviewed customer feedback regularly, identifying trends in common issues and recommending product enhancements accordingly.
- Mentored junior team members, providing guidance on best practices and professional development opportunities.
- Developed staff training programs to ensure consistent service quality across the team.
- Managed a team of support professionals, fostering an environment of collaboration and growth.
- Collaborated with other departments to address customer needs holistically and provide comprehensive solutions.
- Cultivated strong relationships with key clients through proactive communication and personalized attention to their unique needs.
- Facilitated regular meetings to discuss ongoing challenges, share successes, and foster teamwork among staff members.
- Conducted regular performance evaluations for team members, offering constructive feedback and opportunities for growth within the organization.
- Spearheaded cross-functional initiatives aimed at improving overall product quality, leading to reduced support requests from customers.
- Coached employees through day-to-day work and complex problems.
- Collaborated with other teams to identify and resolve customer issues quickly and professionally.
- Created, prepared, and delivered reports to various departments.
- Assessed personnel performance and implemented incentives and team-building events to boost morale.
- Resolved issues through active listening and open-ended questioning, escalating major problems to manager.
- Hired, managed, developed and trained staff, established and monitored goals, conducted performance reviews and administered salaries for staff.
Auditor
Southwest Service Administrators
12.2019 - 09.2020
- Audit sixty complex medical / dental claims per day and provide audit error statistics reports monthly
- Evaluate Provide root cause analysis of trending audit errors
- Provide timely and constructive performance feedback on audit errors
- Provided detailed documentation on audit findings, facilitating swift corrective action when necessary.
- Maintained confidentiality, handling sensitive information discreetly throughout all stages of the audit process.
- Ensured compliance with regulatory requirements by performing regular audits and staying up-to-date on industry standards.
Audit Manager (Compliance Team)
Avesis
12.2015 - 10.2019
- Managed 12 Compliance Auditors and 1 Team Lead
- Assist with the development and implementation of the Claims Audit Tool to maximize efficiency in audit reporting and higher production outputs
- Developed and implemented policies, procedures and processes for auditing providers credentials and Compliance Team
- One on One meetings and performance appraisals
- Coaching and training development sessions with team
- Provide timely and constructive performance feedback
- Communicating expectations provides employees with training resources and information!
- Identified opportunities for process improvement resulting in 100% quality
- Ensure accurate and timely processing, payments, and trends
- Managed a team of auditors, ensuring accurate and timely completion of audit projects.
- Maintained up-to-date knowledge on accounting standards and best practices to ensure high-quality audit results were delivered consistently.
- Implemented risk-based auditing strategies, resulting in better identification of potential issues.
- Coordinated, managed and implemented auditing projects and prepared for evaluation.
Claims Supervisor
Meritain / Aetna
07.2014 - 11.2015
- Supervised, trained, coached, and mentored a team of sixteen claim processors
- Managed claims for 400+ health Plans in multiple states, production standards exceeded
- Ensure accurate and timely claims processing with a goal to exceed production standards
- One on one meetings and performance appraisals
- Coaching and training development sessions with the team
- Provide timely and constructive performance feedback
- Communicating expectations provides employees with training resources and information
- Interview for new hires
- Conduct internal audit of claims completed by processors monthly
- Utilize audit findings as an opportunity for improvement and opportunity to coach for excellence
- Maintained up-to-date knowledge of industry trends and regulations, ensuring adherence to all relevant guidelines.
- Contributed to the creation of a positive work environment through open communication and proactive problem-solving initiatives.
- Oversaw regular audits of processed claims to identify patterns of error or potential fraud indicators.
- Participated in strategic planning sessions aimed at enhancing service offerings for clients in the managed care sector.
- Self-motivated, with a strong sense of personal responsibility.
- Worked effectively in fast-paced environments.
- Skilled at working independently and collaboratively in a team environment.
- Proven ability to learn quickly and adapt to new situations.
- Excellent communication skills, both verbal and written.
- Worked well in a team setting, providing support and guidance.
- Demonstrated respect, friendliness and willingness to help wherever needed.
- Assisted with day-to-day operations, working efficiently and productively with all team members.
- Passionate about learning and committed to continual improvement.
- Managed time efficiently in order to complete all tasks within deadlines.
- Organized and detail-oriented with a strong work ethic.
- Paid attention to detail while completing assignments.
- Used critical thinking to break down problems, evaluate solutions and make decisions.
- Strengthened communication skills through regular interactions with others.
Senior Claim Processor
Cigna
03.2013 - 07.2014
- Process complex medical claims for multiple health plans including Medicare, Medicaid, and Commercial
- Exceeded quality metrics by obtaining 100% audits monthly
- Improved claim processing efficiency by streamlining workflows and implementing best practices.
- Reviewed complex claims, utilizing expert knowledge to ensure proper coverage determinations were made.
- Managed external vendor relationships, ensuring seamless coordination between parties involved in the claims process.
- Evaluated departmental performance metrics regularly, identifying areas for improvement and implementing necessary changes.
Short Term Disability Specialist
Matrix Absence Management
03.2011 - 03.2013
- Review and manage short term disability cases for multiple groups nationwide
- Assisted clients in understanding their rights and responsibilities under the Social Security Disability program.
- Manage Member / Provider Inquiries
- Quality / Production metrics at 100%
- Negotiated reasonable accommodations with employers on behalf of disabled employees, promoting workplace inclusivity and equal access opportunities.
- Remained up-to-date on industry trends and advancements in disability support services, leveraging this knowledge to better serve claimants and their families.
- Managed complex cases involving multiple diagnoses or challenging circumstances, demonstrating exceptional problem-solving skills in navigating logistical hurdles.
Claims Manager
North American Medical Management
09.2001 - 12.2010
- Managed, trained, and successfully motivated a team of 25+ processors for Medicaid, Medicare, and Commercial plans
- Responsible for the financial claims aspect of the company’s capitation reconciliation statements
- Create processes to standardize procedures for improved efficiency
- Ensure accurate and timely claims adjudication, payment processing and auditing
- Lead system conversion and testing on all aspects prior to going live
- Meet and exceed quality and production metrics consistently
- Developed and maintained policy and procedure manuals for claims
- Collaborated with other departments to improve overall organizational effectiveness in addressing client needs.
- Enhanced customer satisfaction with timely and accurate claims resolutions.
- Streamlined communication between adjusters and clients, expediting claim resolution times.
- Implemented quality assurance measures, monitoring staff performance and providing constructive feedback for continuous improvement efforts.
Claims Supervisor
Mercy MSO
05.2000 - 09.2001
- Evaluate and analyze workflow, develop reporting, and policies and procedures for the department
- Supervise team of Claims examiners consisting of eight direct reports
- One on one meetings and performance appraisals
- Coaching and training development sessions with the team
- Provide timely and constructive performance feedback
- Communicating expectations provides employees with training resources and information
- Interview for new hires
- Review and respond to Provider Requests
- Perform random claim audits
- Perform root cause analysis on claim processing errors to improve quality and accuracy results
- Collaborate with internal departments to discuss audit findings, and trends monthly
- Implement process Improvements by way of training, coaching, and mentoring of team members
- Monitored performance metrics regularly, identifying areas for improvement and implementing corrective measures accordingly.
- Assisted in the recruitment and selection of new claims adjusters, ensuring they possessed the necessary skills and expertise to excel in their roles.
- Fostered a positive work environment that promoted collaboration, teamwork, and open communication among staff members.
- Managed a diverse caseload, prioritizing tasks effectively to meet strict deadlines and maintain quality standards.
Claims Manager
Health System Consultants-TPA
06.1984 - 01.2000
- Manage team of claims adjudicators, appeals, stop-loss, and clerical teams, managing multiple products
- Implement policies and procedures within each claim unit
- Process complex stop-loss claims according to contract exclusions
- One on one meetings and performance appraisals
- Coaching and training development sessions with team
- Provide timely and constructive performance feedback
- Communicating expectations provides employees with training resources and information
- Interview for new hires
- Manage team system conversion process
- Report departmental operating statistics and capitation review, to make needed adjustments
- Perform root cause analysis on claim processing errors to improve quality and accuracy results
- Collaborate with internal departments to discuss audit findings, and trends monthly
- Collaborated with other departments to improve overall organizational effectiveness in addressing client needs.
- Enhanced customer satisfaction with timely and accurate claims resolutions.
- Streamlined communication between adjusters and clients, expediting claim resolution times.
- Implemented quality assurance measures, monitoring staff performance and providing constructive feedback for continuous improvement efforts.
Education
Business Administration -
Southern Illinois University
Carbondale, ILCertified Medical Assistant -
Bryman School Of Chicago
Chicago, ILSkills
- Claims & Audit Leadership
- Root Cause Analyst
- Workflow Adherence
- Meet/Exceed Goals & Standards
- Inventory Management
- Attendance Management
- Process Improvement
- Various Claims Systems
- Policies & Procedures
- Customer relations
- Expert problem solving
- Analytical thinking
- Documentation management
- Quality assurance
- Management collaboration
Accomplishments
- Achieved efficiency through effectively managing backlog inventory from 50k down to 15k
- Achieved 100%accuracy through Implementation of Claims Audit Tool.
- Achieved quality performance by implementation of training ,coaching and mentoring team members
- Supervised team of 25 staff members
- Achieved production increase by implementation of process improvements and claim audit tool
Timeline
Workers Comp Specialist
Vensure Employer Solutions
06.2024 - Current
Claims Support Supervisor
TriWest Healthcare Alliance
09.2020 - 05.2024
Auditor
Southwest Service Administrators
12.2019 - 09.2020
Audit Manager (Compliance Team)
Avesis
12.2015 - 10.2019
Claims Supervisor
Meritain / Aetna
07.2014 - 11.2015
Senior Claim Processor
Cigna
03.2013 - 07.2014
Short Term Disability Specialist
Matrix Absence Management
03.2011 - 03.2013
Claims Manager
North American Medical Management
09.2001 - 12.2010
Claims Supervisor
Mercy MSO
05.2000 - 09.2001
Claims Manager
Health System Consultants-TPA
06.1984 - 01.2000
Business Administration -
Southern Illinois University
Certified Medical Assistant -
Bryman School Of Chicago
Work Preference
Work Type
Full TimeLocation Preference
RemoteHybridWork Availability
monday
tuesday
wednesday
thursday
friday
saturday
sunday
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evening
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Quote
Try not to become a man of success. Rather become a man of value.
Albert Einstein
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