Michelle Burgess

· Meticulous approach to facilitating all external regulatory audits, finance audits and HEDIS audit requests with operational business partners for Community & State (C&S) and the Individual and Family Plan (IFP) lines of business.

· Established a regimented and effective audit model within C&S and IFP.

· Provide Operations and Experience teams full support in coordination of state audits responses and interview preparation.

· Manage deliverable adherence to all pre-defined due dates and quality guidelines.

· Integrated an effective and established audit model into the IFP audit space molded after the established C&S audit model in support of operations.

· Highly detail-oriented with the ability to effectively manage multiple priorities and responsibilities simultaneously and with accuracy.

· Drove or led cross-functional responses with teams to ensure comprehensive and cohesive responses and support.

· Mentored new team members and developed a training regime for onboarding.

· Initiated coaching and development opportunities to ensure team cohesion and alignment with new processes.

· Communicated identified pre-onsite risk with health plan and business leaders and developed approach to disclosing/speaking to risk.

· Ensured consistency, communication and transparency with business partners and leaders, audit management and health plan throughout the audit process.

• Support audit Facilitator with all aspects of the process including: Audit Intake, Quality Review and submission of audit documents.
• Ensure adherence to deliverable due dates by implementing a regular cadence of outreach and follow up with business partners
• Conduct thorough quality review of deliverable materials, data and case files.
• Coordinated deliverable feedback sessions with business partners
• Constructed detailed, all-inclusive and at times cross-functional claim case file packets for C&S and IFP business
• Ability to shift focus quickly due to audit needs and priorities
• Adhered to team processes and procedures according to the team's defined practices

• Expert in review and analysis of claim issues to determine the appropriate resolution
• Performed deep dive analysis of complex claim and system issues for CSP Facets
• Implemented corrective action plans, immediate fixes, and system fixes for errors identified in the audit process for CSP Facets
• Generated audit outcome summary, risk analysis, and trending reports using results from analysis of claim data
• Documented research, steps taken, and final disposition of all errors and communicated findings to internal business partners and external clients
• Responsible for all aspects of claim calibration including tracking and compilation of errors, submission to intake sites, and follow up
• Experience with CSP Facets Provider and Benefit End-to-End claim review
• Assisted with the creation of calibration and remediation SOP's

• Responsible for the remediation of errors found during Fully Insured and E&I audits
• Proficient with Commercial Lines of Business and Unet
• Worked closely with the Client Managers to ensure claims were adjusted, claim projects were completed, and Source of Truth documentation was updated
• Initiated meetings with Case Installation to ensure appropriate system fixes were implemented (Benefit updates, SAM Edits, Front/Back-end SPI's)
• Requested and scrubbed claim impact reports and documented results

• Established a positive learning environment that fostered open communication and encouraged continuous improvement among trainees.
• Implemented innovative instructional strategies to accommodate diverse learning styles and optimize knowledge retention.
• Collaborated with management to identify training needs, aligning curriculum with organizational objectives.
• Managed scheduling and logistical elements of in-person and virtual training events, ensuring smooth delivery of content.
• Enhanced operational efficiency by developing and implementing comprehensive training programs for new hires.
• Facilitated cross-functional collaboration within the organization by leading hands-on workshops.
• Provided coaching and mentoring to employees.
• 2 years of CSP Facets Hospital and Medical claims training with proficiency in Medicaid and Medicare products.

• Mentored team members, contributing to their professional growth and development.
• Responsible for daily inventory reports and queue assignments.
• Implemented cross-training sessions for new processes.
• Assisted processors and mentored new hires as an on the job trainer.
• Developed and maintained Standard Operating Procedures and training documents
• Facilitated team meetings and participated in various meetings with business partners.

• Processed complex medical claims while maintaining high quality and production standards.
• Frequently load balanced with appeals, adjustments and projects.
• Received promotion from grade level 22 to 23 for continuously demonstrating efficient claims processing, as well as maintaining high quality standards.