Kimberly Greene
Somerdale,NJ
Summary
Highly qualified Quality Management Specialist with 23 years of experience in managed care responsible for managing external appeals as well as handling a caseload and administrative duties. Accomplished Specialist drives organizational improvements through leveraging expertise in research and system enhancement. Well-versed in collaborating with employees and leaders to resolve control and procedural problems negatively affecting business operations. Dedicated to cost, process and resource optimization. Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals.
Overview
23
23
years of professional experience
Work History
Quality Management/Compliance Administration
Independence Blue Cross
08.2019 - Current
- Knowledge of HIPAA, Corporate Compliance and Policy and Procedures
- Update and create desk procedures for the External Appeal area Manage Intake and triage of commercial external appeals and AHCA cases assign daily -prepare case files for both clinical and administrative review Assist Appeals staff for outreach to members to consent Level I Appeals, Assist QM Specialists RNs with 3rd level appeals, verify information in INSINQ and Beacon Conduct QA audits on QM Specialists for compliance documentation and administrative appeals Knowledge of Center for Medicare and Medicaid Services (CMS) and Stars data per NCQA standards and auditing measures Knowledge of Medicare Advantage plans per compliance education requirements Knowledge of ACT68, DOBI, ERISA and Member Appeals regulations and compliance Research performed on DE, NJ and PA regulation requests received via email Manage tracking and trending of Acknowledgement and Determinations letters sent to AmeriHealth Caritas and appeal assignments to DOH and OMT Reports monthly
- Manage external review appeals for Medicaid personal assistance services daily by assigning 50 cases a week to staff, as well as reviewing and processing a daily caseload as well as Commercial cases, rotation of AHCA calls from members regarding their external appeal outcome Train new hires on intake and triage of external appeal assignments and external appeals Assist with precepting new hires, both RNs and Senior Appeal Specialists Have expand role in processing commercial appeals as well as a resource to team daily
Business Analyst
Independence Blue Cross Family of Companies
09.2012 - 08.2019
- Create year end Annual Supplement report for State – Department of Health (DOH) and network trend analysis Handled disruption and GEO access reports for sales department Manage Member and Provider Complaints for quality of care and service issues including Medicare members and interaction with provider offices and members
- Knowledge of HIPAA, Corporate Compliance and Policy and Procedures
- Update and create desk procedures for the QM complaint area Assist nurse with Occurrences for quality of care and service issues Assist Appeals staff for outreach to members to consent Level I Appeals, Assist QM Specialists RNs with 3rd level appeals, verify information in INSINQ and Beacon Conduct QA audits on QM Specialists for compliance documentation and administrative appeals Manage QM reports – Member Satisfaction reports for Commercial and Marketplace data, accessibility, and network adequacy reports to follow NCQA guidelines
- Annotate and redact documentation for HIPAA compliance guidelines.
Quality Auditor II – Senior
Horizon NJ Health
01.2001 - 01.2012
- Knowledge of National Committee for Quality Assurance (NCQA) and URAC and Healthcare Healthcare Effectiveness Data and Information Set (HEDIS) standards
- Quality Management auditing to ensure plan and provider adherence to evidence-based standards of care- Conduct on-site medical record reviews at physicians’ offices to include Maternity, EPSDT (Early Periodic Screening and Diagnosis and Testing), Medical Record Reviews, Appointment Availability and HEDIS audits
- Checked facets for claims on HEDIS measures to contact members for preventative care
- Assist in data cleanup by analyzing data in Excel Spreadsheets and Access databases – create queries Follow up of corrective action plans from provider offices after audits that were non-adherent Audit lead on nonclinical audits: 24-hour audit: Responsible for tracking data for 24-hour access audits – generate monthly letters to mail out to providers non-adherent and adherent – collaborating with Provider Relations Department
- Responsible for preparing year-end report with data analysis of 24-hour results annually which is presented at CQI (Continuous Quality Improvement) meeting by manager of Quality Management
- Oversight of Policy and Procedure revisions related to non-clinical audits
- Developed and conducted training for in-house and outside auditors
- Assessed inter-rater reliability to prepare for medical chart reviews and data collection for HEDIS audits Quality Improvement Coordinator Attend Peer Review Committee (PRC) Meetings – assist 6 medical directors and managers to discuss quality of care issues Conduct on-site reviews at physicians’ offices for Medical Record Reviews and Appointment Availability and HEDIS audits
- Track cases in Case Trakker for Quality Management referrals from Member Complaints, Appeals, and any other business units for quality of care
Education
Master of Science in Healthcare Administration -
Rosemont College
Philadelphia, PA05.2019
Bachelor’s in science business administration -
Rider University
Lawrenceville, NJ12.2011
Associate in Science – Pre-Nursing -
Camden County College
08.2007
Skills
- Microsoft Office - Word, Excel I, II, Access I, II (create queries) Outlook
- VISIO, PowerPoint, Facets, Source I claim system, Quest analytics Suite
- Visual Cactus, MAXMC, INSINQ, MAS, intranet, internet research, Beacon-VAM, SharePoint, Teams and Adobe Acrobat Standard, Adobe Reader and Writer, Electronic Health records and Catalyst
- Leadership skills – project lead for nonclinical audits, trained new hires on Quality Management referrals, Med Capture software for hybrid measures
- Customer service skills – contacting members, providers, and facilities with regards to quality of care and service
- Teamwork – team project with coworkers – created corrective action plan (CAP) for completed reviews
- Business Analysis - network trend analysis reports
- Data Collection - Medical record reviews such as HEDIS and processing of external appeals
References
Available Upon Request
Timeline
Quality Management/Compliance Administration
Independence Blue Cross
08.2019 - Current
Business Analyst
Independence Blue Cross Family of Companies
09.2012 - 08.2019
Quality Auditor II – Senior
Horizon NJ Health
01.2001 - 01.2012
Master of Science in Healthcare Administration -
Rosemont College
Bachelor’s in science business administration -
Rider University
Associate in Science – Pre-Nursing -
Camden County College
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