Summary
Overview
Work History
Education
Timeline
Generic

Ronnie Adams

Southfield,MI

Summary

Forward-thinking Manager with comprehensive experience implementing new processes and managing and planning innovations. Bringing outstanding problem-solving and abilities paired with in-depth knowledge of policies and procedures. Polished in evaluating employee performance and overseeing key projects.

Overview

11
11
years of professional experience

Work History

Manager- Payment Integrity Operations

BCBSM
Detroit, MI
11.2022 - Current
  • Monitored and improved efficiency of processes, team performance, and customer service.
  • Collaborated with management team on long-term strategic planning initiatives for the organization.
  • Developed and implemented operational procedures to ensure quality standards are met.
  • Directed operations staff by providing guidance, training, and support in order to meet company objectives.
  • Managed staffing needs through recruitment, selection, onboarding and training, disciplinary action as necessary.
  • Implemented innovative strategies that reduced operating costs while maintaining high levels of customer satisfaction.
  • Coordinated cross-functional teams to ensure timely delivery of products and services.
  • Analyzed data from daily reports to identify trends in production performance metrics.
  • Developed key performance indicators to measure effectiveness of operational processes.
  • Conducted regular reviews of existing policies and procedures for continuous improvement opportunities.
  • Aided senior leadership during executive decision-making process by generating daily reports to recommend corrective actions and improvements.
  • Enforced federal, state, local and company rules for safety and operations.
  • Measured and reviewed performance via KPIs and metrics.
  • Identified areas of deficiency and performed root-cause analysis to solve problems.
  • Responded to information requests from superiors, providing specific documentation.
  • Conducted regular meetings with existing vendors to discuss current performance levels.
  • Coordinated with vendors to ensure timely delivery of products and services.
  • Created detailed requirements documents based on customer needs and specifications.
  • Collaborated with other departments to ensure the successful execution of projects.
  • Tracked progress against deliverables using appropriate software tools such as Microsoft Project.
  • Monitored progress on all assigned projects, identified potential areas of improvement, and implemented corrective actions as needed.
  • Facilitated resolution of technical issues arising during different stages of development cycles.
  • Provided regular reports to upper management on project performance metrics.
  • Reviewed project risks and devised proactive strategies to avoid potential roadblocks.

Supervisor- Claims Payment Integrity

COBX
Southfield, MI
09.2019 - 11.2022
  • Identified areas for improvement, narrowing focus for decision-makers in making necessary changes.
  • Set specific goals for projects to measure progress and evaluate end results.
  • Streamlined workflow processes, reducing project completion times.
  • Led weekly team meetings to discuss progress, address issues, and plan future actions.
  • Implemented new operational procedures, increasing efficiency.
  • Implemented quality control measures, significantly reducing error rates.
  • Managed team of XX employees, ensuring high productivity and quality standards were met.
  • Developed and implemented operational policies and procedures to ensure efficiency and accuracy of workflows.
  • Performed quality assurance reviews on claims submitted by staff to ensure compliance with company standards.
  • Ensured that all regulatory requirements were met when processing claims including HIPAA privacy rules and state-specific laws related to insurance coverage.
  • Researched complex claim issues in order to resolve disputes between parties involved in a claim.
  • Built financial models to allocate resources, forecast cash and investment needs and make capital budgeting decisions.
  • Coordinated responses to regulatory inquiries and audits, ensuring timely and accurate compliance reporting.
  • Motivated team members to maintain targeted turnaround time to obtain processing goals.
  • Managed department budget, optimizing resource allocation to meet operational and financial objectives.
  • Established strong relationships with external partners, including adjusters, contractors, and medical providers, to streamline claims resolution.
  • Reviewed settlements, litigation and team best practices to maintain high standards of quality.
  • Maintained databases by creating new records or updating existing ones.
  • Created spreadsheets or other documents using data from internal or external sources.
  • Reviewed and resolved claim issues captured in edits and clearinghouse.
  • Analyzed effectiveness of data entry equipment to secure data integrity across entire system.
  • Monitored data mining results, evaluated accuracy and performance of models, and suggested improvements.
  • Managed a team of analysts responsible for collecting, cleansing, transforming, validating, integrating and loading of datasets into databases or data warehouses.
  • Developed processes for automating routine tasks associated with large scale analytics projects.
  • Performed ad hoc analyses as needed in order to answer specific questions posed by internal stakeholders.
  • Established operational metrics to track progress against goals and objectives related to data mining initiatives.
  • Created reports summarizing findings from data mining activities which were presented to senior management teams.
  • Collaborated with cross-functional teams to refine product concepts.
  • Maintained close relationships with vendors throughout the concept development cycle.
  • Presented concept ideas at internal meetings, demonstrating how they would meet customer needs.
  • Managed the development, implementation, and maintenance of policies, procedures, standards, systems, processes, and tools related to recovery activities.
  • Monitored financial performance of the organization's recovery operations in order to identify opportunities for cost savings or increased efficiency.
  • Conducted regular meetings with team members to review and assess progress of recovery initiatives.
  • Analyzed data to identify areas in need of improvement and develop solutions to address them.
  • Created reports summarizing progress against established goals and objectives.
  • Assisted with the development of financial models used in forecasting future cash flows from recoveries.
  • Performed root cause analysis when necessary to determine underlying issues causing delays or failures in achieving desired results.
  • Developed and implemented strategies for successful completion of recovery goals.
  • Maintained relationships with external vendors providing services related to debt collection and recovery efforts.
  • Established key performance indicators for measuring success in achieving organizational objectives related to recovery efforts.
  • Monitored regulatory changes from CMS or other relevant organizations that impact medical coding practices.
  • Analyzed provider documentation to ensure accurate coding of diagnoses and procedures according to CMS Medicare Risk Adjustment Coding Guidelines.
  • Conducted regular audits of charges submitted to ensure accuracy and compliance with CMS regulations.
  • Participated in external audits conducted by regulatory agencies such as CMS or JCAHO to ensure compliance with applicable laws.
  • Evaluated new coding guidelines issued by regulatory bodies such as CMS or AHIMA.
  • Maintained a working knowledge of CMS coverage determinations, LCDs and NCDs, CPT codes and modifiers.
  • Developed detailed knowledge of CMS guidelines related to reimbursement for services provided under both parts A &B.
  • Maintained current knowledge of changes related to ICD-10, CPT and HCPCS codes, modifiers, CMS regulations.
  • Responded promptly to audit requests from internal departments or external agencies such as CMS or Joint Commission.
  • Maintained up-to-date knowledge of changes in CMS regulations pertaining to Medicare billing codes and requirements.
  • Interpreted and applied billing regulations as set forth by government agencies such as CMS, Medicaid, Medicare Advantage Plans.
  • Participated in meetings, trainings pertaining to coding updates, changes from CMS and other payers.
  • Ensured that all documentation was completed according to standards established by CMS guidelines.
  • Analyzed data trends from various sources including but not limited to, CMS claims data, Quality Measures Reports, OBRA assessment scores, in order to identify areas of improvement or potential risk.
  • Interpreted policy changes from regulatory agencies such as CMS or Joint Commission.
  • Analyzed data trends from surveys conducted by external agencies such as CMS or Joint Commission accreditation bodies.
  • Developed reports based on data collected from the CMS website regarding provider reimbursements.
  • Oversaw daily operations of the unit to ensure compliance with regulatory requirements such as OSHA, HIPAA, CMS regulations.
  • Attended training sessions conducted by CMS representatives on updates pertaining to changes in policy or procedures related to Medicare Claims Processing.
  • Ensured compliance with applicable regulations such as HIPAA Privacy Standards and CMS guidelines.

Lead Recovery Analyst- Payment Integrity

COBX
Southfield, MI
01.2019 - 09.2019
  • Reviewed and updated customer data in order to improve recovery processes.
  • Maintained detailed records of all recovery activities.
  • Created reports summarizing the success rate of various data recovery operations.
  • Evaluated current policies related to disaster preparedness and recommended changes as needed.

Configuration Analyst

BCBSM
Detroit, MI
05.2017 - 01.2019
  • Tested system configurations by running simulations using various scenarios.
  • Created documentation outlining the process for creating and maintaining system configurations.
  • Researched available solutions for implementation into current system configurations.
  • Maintained detailed records of all system configuration activities including any changes made or tests performed.
  • Implemented new configurations based on customer requirements or industry standards.
  • Assisted with the development of user acceptance testing plans related to configuration changes.
  • Analyzed system requirements to develop systems configuration plans and procedures.
  • Collaborated with developers and other stakeholders to ensure that all proposed configuration changes met established standards and criteria.
  • Investigated issues related to incorrect or incomplete system configurations, providing recommendations for corrective action when necessary.
  • Troubleshot program and system malfunctions to restore normal functioning.
  • Created detailed reports on system configurations, changes and upgrades.
  • Identified gaps between existing environment and desired end state when configuring new systems or making changes to existing ones.
  • Developed test plans and scripts for verifying functionality after changes were made to the environment.
  • Resolved complex configuration issues by analyzing logs, identifying root cause of problem, researching possible solutions, testing fixes, documenting results.
  • Managed user accounts within Active Directory; configured access rights and privileges as needed.
  • Analyzed user requirements to develop technical solutions that met business needs.
  • Evaluated pending claims to identify and resolve problems blocking auto-adjudication.
  • Reconciled discrepancies between the Explanation of Benefits statement and the submitted claim form.
  • Responded to inquiries from members regarding their health care benefits.
  • Identified trends in denied claims to improve adjudication processes.
  • Communicated decisions about claims via phone or written correspondence with providers.
  • Investigated complex cases involving multiple providers, services, or diagnoses.
  • Attended continuing education seminars related to changes in laws or regulations governing health insurance policies.
  • Researched policy provisions to determine coverage levels, limitations, and exclusions.
  • Collaborated with other departments within the organization in order to resolve issues quickly.
  • Performed audits on provider billing practices to ensure compliance with regulations.
  • Applied knowledge of coding systems such as ICD-10, CPT, and HCPCS to accurately process claims.
  • Reviewed provider reimbursement requests for accuracy and adherence to contractual agreements.
  • Partnered with internal stakeholders such as actuaries, underwriters, and customer service representatives in order to maximize efficiency.
  • Verified insurance coverage and eligibility for services provided.
  • Assessed denials based on established criteria and procedures.
  • Evaluated insurance claims to ensure accuracy and completeness of documents.

Customer Service Analyst

BCBSM
Detroit, MI
05.2015 - 05.2017
  • Responded promptly to all incoming inquiries from both internal and external sources.
  • Provided excellent customer service by responding to inquiries in a timely and professional manner.
  • Conducted quality control checks on all customer service operations.
  • Monitored trends in customer feedback to recommend process improvements.
  • Investigated complex problems reported by customers and identified solutions.
  • Maintained up-to-date records of customer interactions and transactions.
  • Collected deposits or payments and arranged for billing.
  • Increased customer satisfaction ratings by effectively answering questions, suggesting effective solutions, and resolving issues quickly.
  • Developed and maintained positive relationships with customers through effective communication.
  • Assisted in training new members of the Customer Service Team.
  • Analyzed customer inquiries and complaints in order to provide accurate solutions.
  • Managed escalations from customers who were not satisfied with initial response.
  • Developed strategies for improving customer service processes and procedures.
  • Created detailed reports regarding customer service activities and performance metrics.
  • Responded to customer inquiries via phone, email and chat.
  • Collaborated with other departments to ensure that each request was handled properly.
  • Monitored vendor performance metrics to identify areas of improvement.
  • Collaborated with internal stakeholders to assess current processes, procedures and vendors.
  • Generated monthly reports on vendor performance, pricing trends and cost savings opportunities.
  • Reviewed purchase order requests for accuracy before submitting them for approval.
  • Executed purchase orders based on approved requisitions from internal departments.
  • Investigated discrepancies between invoices and purchase orders for resolution with vendors or internal departments.

Medicare Customer Service Representative

BCBSM
Detroit, MI
09.2013 - 05.2015
  • Performed outreach activities such as attending community events or engaging in marketing campaigns.
  • Participated in team meetings to discuss best practices for responding to customer inquiries.
  • Created documents such as letters, emails, or forms as needed for customer service purposes.
  • Followed up with customers via telephone or email to ensure that their needs were met.
  • Assisted customers in navigating the Medicare website, helping them to find the resources they needed.
  • Resolved customer complaints and concerns in a timely manner.
  • Provided guidance and support to customers regarding billing issues and payment plans.
  • Evaluated existing processes and procedures for effectiveness and efficiency improvements.
  • Identified potential fraud cases involving Medicare beneficiaries.
  • Assisted customers in understanding their rights under applicable laws.
  • Responded promptly to customer inquiries about coverage options, claims status, and other related topics.
  • Provided technical assistance when necessary by troubleshooting any problems with online accounts or applications.
  • Answered incoming calls from Medicare beneficiaries, providing them with information regarding their benefits.
  • Monitored changes in regulations affecting Medicare services provided.
  • Cooperated with Medicare, Medicaid and private insurance providers to establish relationships and resolve billing issues.
  • Provided beneficiaries with information about plan benefits and eligibility determinations.
  • Exceeded established service goals while leveraging customer service, sales and employee management best practices.
  • Mentored junior team members and managed employee relationships.
  • Provided top quality control and eliminated downtime to maximize revenue.
  • Updated system with order specifics and customer details, preferences, and billing information.
  • Increased customer satisfaction ratings by effectively answering questions, suggesting effective solutions, and resolving issues quickly.
  • Enhanced productivity and customer service levels by anticipating needs and delivering outstanding support.

Education

Bachelor of Science - Public Administration

Central Michigan University
Mount Pleasant, MI
05-2015

Timeline

Manager- Payment Integrity Operations

BCBSM
11.2022 - Current

Supervisor- Claims Payment Integrity

COBX
09.2019 - 11.2022

Lead Recovery Analyst- Payment Integrity

COBX
01.2019 - 09.2019

Configuration Analyst

BCBSM
05.2017 - 01.2019

Customer Service Analyst

BCBSM
05.2015 - 05.2017

Medicare Customer Service Representative

BCBSM
09.2013 - 05.2015

Bachelor of Science - Public Administration

Central Michigan University

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Ronnie Adams