Ronnie Adams
Southfield,MI
Summary
Experienced Leader and Program Manager, strong planner, and problem solver who readily adapts to change, works independently, and exceeds expectations. Able to manage multiple priorities and meet tight deadlines without compromising quality. Insightful Manager with experience directing and improving operations through effective employee motivational strategies and strong policy enforcement. Proficient in best practices, market trends and regulatory requirements of industry operations. Talented leader with analytical approach to business planning and day-to-day problem-solving.
Overview
11
11
years of professional experience
Work History
Manager- Payment Integrity Operations
BCBSM
01.2022 - Current
- Lead the implementation of claim overpayment recovery and cost avoidance initiatives
- Ensure data validation, control measures, and reconciliation activities are executed and review results with team members
- Lead vendor oversight and operations for contracted recovery services
- Hire, supervise, coach, mentor, and develop team members
- Collaborate and communicate with Medicare operational leaders, vendors, and support areas on claim recovery and cost avoidance initiatives
- Understand and apply CMS guidance with respect to MA program regulations, Medicare/Internal claims processing policy, and industry billing practices to identify claim overpayment recovery opportunities
- Report anomaly in value identified for large customers such as variance in forecast vs
- Actuals, or previous year performance vs
- Current year performance
- Draft executive summaries as needed for funding requests and contract updates, as needed
- Represent PI on initiatives with potential impact to Data Mining program, including supporting adhoc requests from leadership
Supervisor-Payment Integrity
COBX
01.2019 - 01.2022
- Lead the implementation of claim overpayment recovery and cost avoidance initiatives
- Ensure data validation, control measures, and reconciliation activities are executed and review results with team members
- Lead vendor oversight and operations for contracted recovery services
- Hire, supervise, coach, mentor, and develop team members
- Collaborate and communicate with Medicare operational leaders, vendors, and support areas on claim recovery and cost avoidance initiatives
- Understand and apply CMS guidance with respect to MA program regulations, Medicare/Internal claims processing policy, and industry billing practices to identify claim overpayment recovery opportunities
- Report anomaly in value identified for large customers such as variance in forecast vs
- Actuals, or previous year performance vs
- Current year performance
- Draft executive summaries as needed for funding requests and contract updates, as needed
- Represent PI on initiatives with potential impact to Data Mining program, including supporting adhoc requests from leadership
Lead Recovery Analyst-Payment Integrity
COBX
01.2019 - 01.2019
- Establish and manage workflow
- Monitor, track, and report COB and Recovery activities in IkaSystems
- Ensure timeliness is met and expected outcomes achieved
- Lead the implementation of new processes and policy requirements
- Lead the identification of process improvement opportunities
- Identify barriers and lead the development of solutions
- Support control validation oversight and analyze data to ensure quality and maintain compliance with CMS requirements and MA policies
- Support vendor oversight and operations for contracted services
- Train, coach, and mentor team members
- Provide feedback on team performance
- Serve as a subject matter expert regarding CMS MA policies related to COB and Recovery
- Represent the department on cross departmental work groups and committees.
Configuration Specialist-Claims Operations
BCBSM/COBX
01.2016 - 01.2019
- Lead benefit, enrollment, and billing configuration in IkaSystems on both an annual and ongoing basis
- Responsible for running claims through the IkaSystems in multiple real-life scenarios to ensure consistency in running and reporting claims, and to ensure compliance with both State and Federal CMS and Medicare Advantage regulations
- Participate in work groups in order to develop and improve workflows and business processes within area(s) to improve customer service and decrease operational costs
- Lead projects/teams in order to produce desired results
- Responsible for corporate communication of project results
- Assure that corporate compliance is communicated, implemented, and monitored on an ongoing basis
- Participate in systems testing, develop procedures/controls and provide recommendations for the ongoing improvement of the updated process
- Assist personnel (both internal and external) by answering questions, supplying information and training
- Maintain an effective working relationship with clients.
Analyst-Vendor Management
BCBSM
01.2015 - 01.2016
- Responsible for assisting and supporting management in the evaluation, recommendation, establishment, implementation and analysis of new and improved production workflows, work processes for systems, reporting and new products/programs to improve customer service levels and overall quality
- Plan, coordinate, develop, and implement approved projects, which are Divisional and/or Corporate in scope in order to enhance the overall efficiency of operational procedures, methods, controls, and performance
- Participate in systems testing, develop procedures/controls and provide recommendations for the ongoing improvement of the updated process
- Utilize and maintain available production and reporting systems; produce routine and non-routine reports, presentations, letters communications and graphics
- Represent department and division as requested on work groups and special assignments
- Assist in training and curriculum development
- Develop and maintain an effective working relationship with external partners.
Csr Ii-Medicare Advantage
BCBSM
01.2013 - 01.2015
- Assist members and providers with issues via phone, email, and written correspondence
- Investigate enrollment, claims, and benefit inquiries in Ika
- Familiar with CMS processes and guidelines, and fee schedules
- Utilize IkaSystems and various other technologies to complete inquiries
- Utilize analytical skills to research claims processing guidelines and possible system issues
- Exercise efficient time management in maintaining caseload
- Educate members and providers on BCBSM and Medicare policies and procedures
- Assist consultants with inquiries related to claims, pricing, and provider eligibility concerns.
Education
Bachelor of Science - Public Administration
Central Michigan University
Mount Pleasant, MI05.2016
Skills
- Data Analytics
- Vendor Management
- Forecasting
- Financial Reporting
- Budget Management
- Strategic Planning
- Managing Operations and Efficiency
- Financial Management
- Workforce Management
- Staff Development
- Cross-Functional Teamwork
- Policy Implementation
Timeline
Manager- Payment Integrity Operations
BCBSM
01.2022 - Current
Supervisor-Payment Integrity
COBX
01.2019 - 01.2022
Lead Recovery Analyst-Payment Integrity
COBX
01.2019 - 01.2019
Configuration Specialist-Claims Operations
BCBSM/COBX
01.2016 - 01.2019
Analyst-Vendor Management
BCBSM
01.2015 - 01.2016
Csr Ii-Medicare Advantage
BCBSM
01.2013 - 01.2015
Bachelor of Science - Public Administration
Central Michigan University
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