Tiffany Johnson
Somerset,NJ
Summary
Resourceful Manager skilled promoting enhancements to team and company success while maintaining conformance to established and emerging regulations. Certified in Lean six sigma and bringing over 16 years of related experience. Excellent knowledge of state and federal regulations governing Health Insurance Industries in NJ & NY.
Overview
16
16
years of professional experience
Work History
Regulatory Affairs Manager/Government Contracts Lead
Molina Healthcare
Brooklyn, NY
12.2020 - Current
- Review and submit all member facing marketing materials for the Health Plan for state approval
- Resolve all DOH & DFS state complaints via written communication
- Manage relationships with key regulators to identify priorities and positions
- Manage contract renewal activities, lead capture planning for rebids and submission activities
- Engage in contractual, rate and program advocacy
- Maintain and manage day-to-day state contracts with state Medicaid and Marketplace contract managers, including interactions with senior Medicaid and Marketplace regulators
- Oversee the timely implementation of all new legislation, regulations, contract amendments and sub-regulatory guidance
- Primary resource/SME for inquiries from business units regarding all state inquires
- Manage the state-based regulatory filings process
- Enforced regulatory affairs department compliance with agency requirements.
- Monitored organization's internal practices to comply with government regulations.
- Worked with regulatory bodies to negotiate filings, complete applications and report changes.
Sr. Regulatory Affairs Analyst
UnitedHealthcare
Iselin, NJ
12.2019 - 12.2020
- Perform critical and objective review of regulatory information
- Determine whether business processes are consistent/compliant with applicable regulatory requirements
- Collaborate with business partners to review, analyze and oversee/coordinate applicable implementation project plans from a regulatory perspective
- Manage/monitor implementation to ensure that corrective actions and compliance plans are properly implemented
- Create regulatory documents/communications/adhoc
- Analyze and interpret new mandates and laws
- Manage/implement applicable regulatory filings in a timely manner
- Collaborate with applicable stakeholders to manage/support market conduct exams and performance audits
- Monitored regulatory change required by new and revised laws and regulations, communicating complex protocols and determining operational impacts.
Grievance & Appeals Specialist
VNSNY CHOICE
New York, NY
07.2017 - 12.2019
- Resolves grievances, appeals and fair hearing reviews for VNSNY CHOICE product lines
- Ensures regulatory compliance, timeliness requirements and accuracy standards are met
- Coordinates efficient functioning of day-to-day operations
- Creates and maintains accurate records documenting the actions and rationale for each grievance or appeal decision
- Develops correspondence communicating the outcome of grievances and appeals to enrollees and/or providers
- Assists with collecting and reporting data
- Coordinates external case reviews requested by enrollees
- Tracking external reviews
- Develops and maintains current knowledge of state and federal regulatory requirements
Account Manager III
Horizon BCBSNJ
Newark , NJ
12.2015 - 07.2017
- Process and expedite the reconciliation of the member accounts for group administration while educating members and clients on benefits and referral protocol
- Respond to inquiries from members and groups received by telephone or through written correspondence regarding benefits, enrollment, contributions and claims processing
- Serve as Mentor and Coach CDH Account Consultants
- Act as a liaison between Horizon, group administrators and CDH-related vendors and production support
- Track data and Trend analysis as well as reporting
- Coordinate administrative claims appeals on behalf of members
Correspondence/ Appeals Specialist
Horizon BCBSNJ
Newark, NJ
12.2013 - 12.2015
- Acted as intermediary between insurance companies and customers by researching and assessing information to determine claim validity.
- Coordinate with Blue Card Association Home plans to address customers' inquiries regarding claim, benefits and/or appeals
- Ensured accurate and timely resolution of service requests and activities
- Review/escalated issues raised by customers in accordance with guidelines established by management.
- Identified reasons behind denied claims and worked closely with insurance carriers to promote resolutions.
- Called insurance companies to ascertain pertinent information regarding policies and payment benefits for patients.
Call Center Representative
Horizon BCBSNJ
Newark, NJ
04.2008 - 12.2013
- Met or exceeded call speed, accuracy and volume benchmarks on consistent basis.
- Engaged in conversation with customers to understand needs, resolve issues and answer questions.
- Analyzed call logs to determine customer needs and recognize trends in service requests or complaints.
- Interpret codes on all diagnoses, procedures, professional service, and supplies with the most accurate and descriptive ICD-9-CM, CPT-4, and HCPCS codes for all patient encounters for reimbursement
- Verify insurance eligibility, follow-up on all insurance denials
Education
Executive Masters of Healthcare Administration -
Rutgers University
01.2021
Lean Six Sigma Green Belt Certification -
2020
Bachelor of Business Administration - Healthcare Management
Saint Peter’s University
2017
Skills
- Possess knowledge of Managed Care, Medicare, Medicaid, DSNP, FIDE, DOBI, OMHC, DOH, CMS, JCAHO, HIPAA, DFS
- Standard Operating Procedures
- Strong team player
- Strong analytical skills
- Strong oral skills
- Strong problem-solving skills
- Strong data analytics skills
- Audit Oversight
- Strategic Planning
- Staff Training
- Supervision & Leadership
- Microsoft Office
- Project management
Timeline
Regulatory Affairs Manager/Government Contracts Lead
Molina Healthcare
12.2020 - Current
Sr. Regulatory Affairs Analyst
UnitedHealthcare
12.2019 - 12.2020
Grievance & Appeals Specialist
VNSNY CHOICE
07.2017 - 12.2019
Account Manager III
Horizon BCBSNJ
12.2015 - 07.2017
Correspondence/ Appeals Specialist
Horizon BCBSNJ
12.2013 - 12.2015
Call Center Representative
Horizon BCBSNJ
04.2008 - 12.2013
Executive Masters of Healthcare Administration -
Rutgers University
Lean Six Sigma Green Belt Certification -
Bachelor of Business Administration - Healthcare Management
Saint Peter’s University
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