Jennifer T.

Experience

• 

  MAXIMUS

  Oct 2011 - Nov 2012

  Program Technician II

  • Receive applications, documents and renewals for data entry• Process applications and determine appropriate level of eligibility status• Identify potential Medicaid referrals • Update database for changes in circumstances or eligibility status• Exceed individual, team and unit performance goals and standards • Access Texas Integrated Eligibility Redesign System (TIERS) system to verify information• Daily updates of pending tasks based on deadlines• Quality control of every application reviewed• Familiar with TANF, SNAP, and food stamps• Train new/transferred employees• Act as backup supervisor• Lead for special task team of 6• Maintain supervisor inbox for team of 16 people Show less

• 

  DentaQuest

  Nov 2012 - Apr 2015

  • Research, follow up and resolve complaints, grievances, and appeals in a timely manner to ensure member and provider satisfaction in accordance with State and/or Plan guidelines• Escalate issues appropriately and work with other departments to resolve member and provider issues and concerns• Ensure all HIPAA and State requirements/regulations are adhered to at all times• See that complaints and grievances are resolved within the appropriate time constraints• Communicate to management ways to improve processes and productivity for the department• Communicate to the team when there are new problems or changes in process• Work collaboratively with other departments to properly resolve issues• Respond to internal and external inquiries• Assist with State Fair Hearings, Better Business Bureau and Department of Insurance cases to resolve complaints• Assist in training new team members• Provide support to team members for case resolution • Assist with creating process notes for Health Insurance Casework Procedures• Monitor, prioritize and adapt to changing priorities• Participate in C&G Training Focus Group• Act as backup to the Supervisor in TX Market Meetings and reviewing responses to the health plans and HHSC• Dental Director liaison • Other duties and special projects as assigned Show less • Research the assistance requested and consistently provide accurate information to resolve internal and external member and provider inquiries via verbal and written communications through all channels including phone, email and web portal• Assist in the change of primary care dentists for members• Resolve eligibility, history, and benefit issues for members and providers• Advise non-participating providers in steps to become credentialed• Provide backup to special team for faxed/emailed primary care dentist changes• Resolve claim payment inquiries by researching and analyzing patient activity and determine appropriate action to be taken• Assist providers by resolving coordination of benefits inquiries by analyzing patient activity (including enrollment, third party liability, and claims attachments)• Exceed individual and department goals • Adjust claims data, when appropriate, to immediately resolve the inquiry and maintain first call resolution expectations• Special projects as assigned• Provide floor support during management meetings• Appropriately route inquiries to the necessary departments or individuals when resolution of the inquiry is beyond the span of control of this role• Other duties as assigned. Show less

  • Complaints and Grievances Specialist

    Jun 2013 - Apr 2015

  • Customer Service Representative

    Nov 2012 - Jun 2013
• 

  FirstCare Health Plans

  Apr 2015 - Oct 2015

  Complaints and Appeals Specialist

  • Prepare files for appeals to independent review organizations, appeal panels, peer reviews and regulatory agencies• Monitor complaints and appeals for patterns to notify appropriate departments for corrective action• Prepare response letters to members, providers, HHSC, TDI, and CMS.• Maintain tracking logs and case files •Research, follow up and resolve complaints, grievances, and appeals to ensure member and provider satisfaction in accordance with appropriate guidelines

• 

  Fresenius Medical Care North America

  Oct 2015 - Jun 2019

  • Review trends and work with other departments to resolve systemic issues• Ensure that all department activities follow applicable CMS, NCQA, URAC and general accreditationstandards, as well as State and other federal regulatory requirements• Prepare detailed grievance and appeals reports to identify/escalate trends, patterns, discrepancies and improvement opportunities for business owners and determine action plans• Analysis and interpretation of leading root cause resulted in reduction of Provider Customer Service grievances by 25%• Streamlined the inquiry/grievance process to improve the North Carolina Reward Program. After analysis of grievances about the program, implementation of my suggestions reduced grievances by 40%• Liaison between A&G / Utilization Management (UM) department’s users and IT to fix software issues• Software testing (go live and version updates) for functionality of A&G and UM departments modules• Created audit tool for review of A&G and UM cases • Create ad-hoc reports as requested for A&G and UM• Provide training to new hires and serve as a resource to other departments• Validated ODAG report mapping (11 reports) to match CMS requirements and serve as Subject Matter Expert for ODAG, CDAG reporting and CMS audits• Pushed for change in UM process regarding Peer to Peer requests in order to decrease appeal cases. This resulted in a drop of 20% in appeal cases Show less • Managed the receipt, investigation and resolution of an average of 21 grievance cases/month and 13 appealcases/month in a timely and highly effective manner• Resolved 100% of cases reported timely within the allowed turnaround time• Assisted in creation/editing/updating of A&G letters, letter instructions and department’s policies and procedures including annual review• Created and lead training sessions for other departments on the A&G function and expectations• Created letter workbook to test all letters for A&G and UM departments• Detailed knowledge of Chapter 13 of the Medicare Managed Care Manual and Maximus Federal ServicesMedicare Health Plan Reconsideration Process Manual• Covered non-clinical responsibilities while Director was on leave Show less

  • Appeals and Grievances Specialist

    Jun 2018 - Jun 2019

  • Appeals and Grievances Coordinator

    Oct 2015 - Jun 2018
• 

  Superior HealthPlan

  Aug 2019 - now

  •Focus on HIPAA Privacy and Security•Ensure compliance with contractual requirements and federal and state government reporting and regulations.•Maintain government relations for compliance activities.•Attend necessary meetings related to Compliance Risk Management.•Actively participate in Compliance initiatives including Compliance Training Workgroup.•Create and facilitate Compliance Trainings surrounding Risk Management to cross functional teams.•Possess and apply substantial knowledge surrounding multiple state and federal contractual and regulatory requirements related to Privacy and other Compliance areas.•Facilitate active communication across various departments across Superior HealthPlan to meet Compliance Risk Management goals.•Complete requested and required reports and other deliverables to SHP Compliance and various State and Federal regulators in support of daily Risk Management operations and activities.•Monitor various privacy and other risk management platforms including email transmission site, Archer, and other related Risk Management applications.•Offer and provider additional support to Compliance Supervisor in areas related to Risk Management as needed. Show less • Develop and maintain quality and compliance reports and dashboards • Review and analyze deliverables and data reports to ensure timeliness of submission and identify trends in performance and improvement opportunities • Perform and monitor audits, risk assessments and documentation activities to ensure compliance • Identify, investigate, and resolve compliance issues and develop corrective action plans to mitigate future risks • Serve as the “go to” person for all compliance activities including training and awareness programs • Design, implement and improve regulatory documentation and processes to address compliance issues and concerns related to all federal and state regulatory requirements, contract requirements and company standards • Triaging regulatory requests from regulatory agencies (OIG, OAG, HHSC) specifically related potential FWA(Fraud Waste Abuse)• Distributing requests internally to operational areas, setting internal deadlines to ensure that regulatory deadlines are met, conducting QA prior to submission, identifying any errors that do not align with the request criteria, and maintaining a log of all requests received• Manage internal and external deadlines and responses to ensure that Superior Health Plan TX is in alignment with any regulatory needs• Perform and monitor audits, risk assessments and documentation activities to ensure compliance• Identify, investigate, and resolve compliance issues and develop corrective action plans to mitigate future risks• Research new markets and primary source verification to determine licensure requirements and administer ongoing licensure maintenance • Assist with vendor activities, including documentation of all pre- and annual delegate oversight and on-going vendor oversight and partnership activities • Update management on the status and activities pertaining to compliance, contract deliverables and related activities Show less

  • Compliance Specialist - Risk Management

    Sept 2023 - now

  • Compliance and Reporting Specialist - Regulatory Compliance

    Aug 2019 - Sept 2023