Summary
Overview
Work History
Education
Skills
Timeline
Generic

Lichelle Lawry

Tampa,FL

Summary

Over 20 years of Operations Management, Medical Claims Training, Claims Processing and Auditing experience in Commercial, Medicare, and Medicaid Insurance industry. Results driven, highly motivated and experienced Operations Professional. Experienced Medical Systems Trainer with a strong background in FACETS, Nextgen, QXNT, SIR and Macess and NextGen. Experienced in designing and developing course materials for Instructor led and/or online self-directed learning. Effective communicator with exceptional interpersonal, problem solving, and motivational skills.

Overview

25
25
years of professional experience

Work History

Appeal Manager II

Elevance Health
11.2022 - Current
  • Adhere to CMS guidelines to ensure state requirements for Authorization Appeals are reviewed and processed based on contracted processing Turn-around Times (TATs)
  • Take escalated Member/Provider concerns, coordinates service delivery to include member assessment of physical and psychological factors for Member/Provider Pre-Service and Post Service authorization appeals
  • Evaluates current processes, recommends changes for increased efficiencies and improved outcomes
  • Develops and conducts training programs to increase efficiencies and associate growth
  • Extracts and manipulates analytical data to present findings to relevant markets and/or stakeholders
  • Hires, trains, coaches, counsels, and evaluates performance of direct reports
  • Implement Process improvements.

Claims Reconciliation Manager I

Anthem Inc.
02.2020 - 11.2022
  • Manage day-to-day activities of the first level Member/Provider payment disputes
  • Adhere to CMS guidelines to ensure state requirements for claims processing guidelines
  • Take escalated Customer Service concerns Coordinates service delivery to include member assessment of physical and psychological factors
  • Participates in cross-functional workgroups created to maintain and develop program
  • Evaluates current processes of Special Program's support functions; recommends changes for increased efficiencies and improved outcomes
  • Develops and conducts training programs for staff involved in the program
  • Extracts and manipulates analytical data to present findings to relevant markets and stakeholders
  • Hires, trains, coaches, counsels, and evaluates performance of direct reports
  • Implement Process improvements.

Coordination of Benefits Supervisor II

Carefirst BC/BS HealthCare
07.2011 - 12.2019
  • Supervise the day-to-day activities of the Coordination of Benefits department
  • Analyze current policies and operating procedures to include workflow and performance management
  • Develop logical and accurate ADHOC reports to Upper Management regarding inventories, case work and overall Coordination of Benefits monthly savings
  • Administer Staff reviews and Monthly Performance Assessments
  • Coach and Counsel staff on day-to-day activities
  • Take escalated Customer Service Calls and complex claims issues
  • Implement Process improvements.

Care Management Training and Development Specialist

Johns Hopkins HealthCare
08.2010 - 07.2011
  • Provide training to Intake Staff to assist Providers with referrals, authorizations for treatment, and problem resolution
  • Conducts Soft Skills Training to Intake Staff to assists members and Providers by accurately and independently educating providers on the referral and authorization processes
  • Train the Intake Staff to utilize internal processing system to assure that the members are eligible for benefits and that requested services are authorized
  • Conduct training sessions with staff to review authorization requests and how to recognize duplicates to ensure accurate entry of authorization/referrals
  • Audits calls received by Intake Staff across multiple lines of business
  • Provide feedback on a monthly basis based on phone calls and data entry through chair side coaching and mentoring.

Corporate Recruiter

Bravo Health
05.2008 - 07.2009
  • Built relationships with Departmental Heads to ensure the right fit for the department based on experience and personality
  • Pre-screened resumes based for open positions and to also create a pre-screened database for positions with a high turnover rate
  • Schedule interviews and testing for Managers based on a favorable telephone interviews
  • Acted as the point of contact for Managers and potential employees for open positions
  • Met departmental standards in regard to filing open positions in a timely manner
  • Utilized varies search engines to look for great talent
  • Managed on line job postings by adding positing to the online database and managing that a posting is no longer displayed once an offer letter has been initiated
  • Maintained the company database to track the status of candidates
  • Generated Offer Letters and New Hire Packets, explained company policies and company benefits to new employees
  • Generated letters for potential candidates that were not selected for position(s) for which they applied
  • Adhered to Company hiring practices, and reported all issues that did not comply with such practices.

Systems Trainer/Instructional Designer

Bravo Health
12.2007 - 05.2009
  • Collaborated with organizational Managers/Departmental VP’s in the development and implementation of departmental training needs
  • Conducted needs assessments, gap analysis, design of story boards, development, evaluations and implementation based on The Addie Model
  • Participated in the designing process, development and implementation of an enterprise-wide, online reference system for workflows, processes and procedures for the Operations Department
  • Developed and maintained Wiki based technology interface along with the Learning Management System (LMS) an online content repository for just in time access retrieval of business knowledge which contained in over 20,000 pages
  • Served as a Project Manager during the development of extensive and comprehensive Blended Learning Programs for Claims, Customer Service, and Utilization Management
  • These Programs were accessed through classroom instruction, E-Learning, and through self-directed technologies
  • These programs trained over 200 personnel within a 6 week period of time achieving all Go Live launch deadlines
  • Developed and maintained assessments through the Learning Management System (LMS) and via paper to assess the learner’s comprehension of the presented material
  • Tracked the learner’s progress on assigned Learning Programs through the Learning Management System to provide feedback to the Learner and Management Staff
  • Trained new and existing staff on the core operating system; covering all aspects of system functionalities
  • Trained and audited the work of Technical Writers and Content Creators contributing to the material located in the online reference system
  • Analyzed audits and skill assessments to determine the effectiveness of training material
  • Developed security levels for Claims Edit resolutions
  • Updated all system documentation related to the core operating system functionality updates
  • Conferred with subject matter experts and system IT programmers to research and develop over 2,000 pages of print and online workflow documentation of QNXT processing system functionally and user procedures over a 6 month period of time
  • Consulted and developed all text to include; reference material, hand outs, and job-aides
  • Responsible for scheduling all staff for QNXT implementation training, minimizing time spent away from regular operation duties.

Operations Trainer

Trizetto Group
06.2006 - 11.2007
  • Trained Operations staff in all FACETS System functionality as it relates to front and back-end users
  • Conducted weekly performance appraisal with Trainees to be shared with Management Staff
  • Configured FACETS System to generate Provider remits and agent commissions’ checks
  • Designed and delivered system application training utilizing classroom, online conference training and Train the Trainer to end users both in Untied States and India
  • This blended learning approach help save travel expenses, and achieved high bench marks in claim reduction
  • Trained claims processing for HCFA, UB92, Home Health, Dental, Medicare and Medicaid claim and Billing
  • Developed and maintained Online Help Repository for policies and procedures for the Operations staff
  • Processed change request, edited and managed all support documentation and process material both print and online
  • Audited the work of claims processors, which aided in the progression of the trainees reaching production standards of 150 claims per day
  • Identified opportunities for improving training methods and procedures best suited for adult learning.

Medical Claims/Provider Rep. Supervisor

Keystone Mercy Health Plan
03.2002 - 05.2006
  • Managed and delegated claims based on daily inventory to sustain claim processing guidelines mandated by the State
  • Conferred with Providers to routinely educate on: coding, identify error trends and payment policies, which strengthened the relationship between our Providers and the Insurance Company ultimately led to a 95% Provider retention rate
  • Coached, mentored and managed a staff of 25 or more too continuously met daily and monthly production standards
  • Led Team Building exercises to boost team morale, which decreased Average Speed to Answer (ASA) to an average of 15 seconds
  • Managed and conducted the interviewing process for new hire perspectives in the Claims and Provider Claims Department
  • Reduced the department’s turnover rate from 60% to less than 20% in a 4 month period.

Medical Claims Trainer

Keystone Mercy Health Plan
01.2000 - 03.2002
  • Conducted over 25 Corporate Training Programs such as; Sexual Harassment, Team Building Workshops, Diversity Workshops and Management Programs on how to relate to employees
  • Managed and delegated claims based on daily inventory to sustain claim processing guidelines mandated by the State
  • Trained new and existing staff on FACETS functionality as well as stream-lining existing policies and procedures
  • Led Soft Skills Workshops targeted for Member and Provider Claims Service Representatives
  • Developed and maintained all online documentation of processes and procedures used Company wide
  • Assign, schedule, coordinate, and facilitate all aspects of training throughout the Company.

Research Analyst/ Provider Relations Representative

Keystone Mercy Health Plan
04.1999 - 01.2000
  • Maintain a positive relationship between the Provider and Insurance Company by addressing claims processing error and configuration trends
  • Visit Providers offices and/or Facilities to educate those coding errors and work through claim error trends
  • Reprocessing claims and answering Provider related inquires
  • Recover over and underpayments from Providers
  • Audited work that had been processed by the Front End Claims staff
  • Answered incoming calls from the Provider to resolve any provider related issues.

Education

Business Management -

University of Maryland Global Campus
Adelphia, MD

Skills

  • Demonstrate strong leadership skills
  • Advance knowledge of CPT,HCPCS, and ICD10 coding
  • Strong written, oral and communication skills
  • Ability to coach and counsel staff
  • Strong knowledge of the Microsoft Office Suite
  • Strong knowledge of Facets , Macess and SIR imaging systems, Facets Workflow, QNXT and NextGen
  • Documenting experience in Wiki System
  • Testing and Building experience in the Learning Management System (LMS)

Timeline

Appeal Manager II

Elevance Health
11.2022 - Current

Claims Reconciliation Manager I

Anthem Inc.
02.2020 - 11.2022

Coordination of Benefits Supervisor II

Carefirst BC/BS HealthCare
07.2011 - 12.2019

Care Management Training and Development Specialist

Johns Hopkins HealthCare
08.2010 - 07.2011

Corporate Recruiter

Bravo Health
05.2008 - 07.2009

Systems Trainer/Instructional Designer

Bravo Health
12.2007 - 05.2009

Operations Trainer

Trizetto Group
06.2006 - 11.2007

Medical Claims/Provider Rep. Supervisor

Keystone Mercy Health Plan
03.2002 - 05.2006

Medical Claims Trainer

Keystone Mercy Health Plan
01.2000 - 03.2002

Research Analyst/ Provider Relations Representative

Keystone Mercy Health Plan
04.1999 - 01.2000

Business Management -

University of Maryland Global Campus

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Lichelle Lawry