Stanley W. Robinson8044 Montague Ct.Glen Burnie, Md., 21061Home 916-317-6410

stanrobinson2@yahoo.comor swrobinson177@gmail.com

Healthcare Claims Manager/ Consultant/Claims Trainer/ QA Lead

Background Summary

Superior Healthcare and Insurance professional with 20+ years' of expertise in healthcare compensation, payment adjudication, provider reimbursement and quality assurance review. Solid knowledge of claims processing and timely filing procedures with claims inventory management., critical problem solver, researcher, and developer of system implementations pertaining to claims management and in terms of claims resolution as well. Successful in managing time, prioritizing tasks, and organizing projects to improve the quality of claims processing.

Technical Expertise

• Amysis, CICIS/Oracle, Diamond 950c/Excelys, Erisco, and Facet.• AS400, RIMS, Trizetto/QicLink• BlueCard Host System, EZ-CAP and Medi-soft billing. IKASYSTEM, QTP Automation

Professional

Trizetto Corporation 9/2014-present

Claims Operation Fulfillment Manager

Maintain vendor’s contracts in terms of the implementation process for fulfillment. Resolve escalated issues for clients on fulfillment implementation, track implementation process, and creation of BRDs for each client implementation. Attend operational meeting with senior management report out on any issues stemming from implementation. Monitor, audit file output from vendor Emdeon and LaserMark to ensure processes are working correctly and output contains no errors.

Inetico, Inc. 12/13-6/2014

Director of Claims Operation, Tampa, FL (Laid off)

Maintain an 80% success rate of negotiated claims, pre-notification agreement and create, improve written work flows, policies and procedures for claims staff. Monitor work queues and ensure smooth transition of EDI claims to the appropriate queues and network. Responsibility for having claims audited at client requests according to policy and procedures for vendor relation. Implementation and setup of new groups and assignment of appropriate PPO flows. Handle all customer service escalated call from vendors and clients via emails or customer service calls. Assisted IT department implementing Medicare fee schedules for PAR3, PR30 for Inetico PPO line of business and troubleshooting system issues. Perform all other duties and responsibilities as assigned and recognized.

Dell Perot Systems/Synergy, Lincoln Ne 12/2012–12/2013 Software Engineer-QA Tester – (Contract position)

As a contracted employee my duties consist of benefit validation on BCBS-Michigan Medicare Advantage program also, SIT, UAT Claims module, Eligibility module, Billing module, and Provider PPO module for new application enhancements, defect management and regression testing on IKASYSTEM application. All test scripts and execution were recorded on QTP automation tool. MS Project management application was used to monitor the project. This plan has 200,000 member’s lives and 80 difference plans which went live on 1/1/2013 for Dell Perot Systems.

Beacon Health Solutions, Tampa, FL 1/ 2010-11/2012

Claims Manager (Laid off)

Managed Jackson Memorial Hospital Medicaid contract for Beacon Health solution and prior managing Passport Advantage Medicare/Medicaid contract and responsible for hiring of staffing for both contracts, performance appraisal and employees conflict resolution. Primary duties are inventory management, auditing, duties assignment, time service analysis, and system issue and resolutions. Currently managing a staff of 9 claims specialist and maintaining a turnaround time under 15 days for both contracts.

Jacobson Solutions, Chicago, Illinois 2/2009 - 12/2009Claims Consultant-Project Lead Manager (Contract position)Supervise an auditing team performing system configurations to the RIMS/Trizetto platform for United Healthcare PPO provider database. Direct staff in project assignments, inventory tracking, responsible for communicating individual improvements, and identifying any additional departmental needs. Provide analytical expertise in interpreting contracts and reprocessing claims. Set and adjust short-term priorities, prepare time sheets and assign work-load to subordinates.

Jacobson Solutions, Chicago, Illinois (Contract position) 8/2008 – 12/2008Sr. Claims AnalystProcessed Medicare claims on Blue Card Host System for Blue Cross/ Blue Shield of Texas. Exceeded production and quality standards set by Senior Management.

Kaiser Permanente, Oakland, California 2002 - 2007Quality Assurance Coordinator (Medical disability resign)Performed internal audits to ensure operational policies and procedures are administered according to HP benefits for members/groups. Reviewed procedural audit reports of adjudicated claims in compliance with compensation/quality guidelines; utilized audit findings to retrain staff on claims operations. Provided feedback on accuracy and productivity levels and recommended appropriate counseling/training to improve employee work performance. Prepared reports for regulatory agencies and group requirement/mandates related to qualitative goals. Other duties were to assist with resolving issues regarding policy interpretation and contract administration for Medicare Senior Advantage plan.

CBCA, Inc., Folsom, California 2001 - 2002Claims Trainer (Laid off company relocated)Duties were to perform on-site/off-site staff audits and claims training for new and existing employees on group benefits guidelines. Prepared reports to reflect unit compliance for regulatory agencies and group requirement/mandates related qualitative goals for management team. Resolved issues regarding policy

2

interpretation and contract administration; trained new and regular employees on the Diamond 950c systems for group plans and procedure related to that group health plan guidelines, via the National Correct Coding Initiative.

Alliance for Health, Alameda, California 2000 - 2001Claims Supervisor (Laid Off)Managed Medi-Cal claims staff and clerical personnel; monitored claims inventory and processor production and developed new policies and procedures to enhance claims adjudication. Planned, assigned and coordinated work assignments of subordinate staff.

Sterling Staffing, Oakland, California 1997 - 2000Claims Analyst Lead/Sr. Auditor (Contract position)Duties were to conduct membership audits to ensure accurate reconciliation on membership accounts payable for health plans with the City and County of San Francisco. Reviewed eligibility reports for plan discrepancies on membership rates; determined accurate reporting on membership eligibility and premium deduction. Audited historical claims to ensure quality of claims adjudication; instructed training workshops on claims adjudication and policies /procedures; provided customer service regarding health plan issues.

Coresource, Sacramento, California 1994-1995Claims Supervisor, (Laid off company relocated) Supervised claims staff and clerical personnel and monitoring claims inventory and processor production levels. Perform weekly claims meeting with claims staff and reported out to upper management any claims issues, Performed employees appraisal evaluation ran daily report for management, developed new policies and procedure to enhance claims adjudication.  Assoc. Ca. Hosp. District, Sacramento, California 1991-1993 Claims Supervisor, (Laid off-company closed)Supervised claims staff and clerical personnel and monitoring claims inventory and processor production levels. Perform weekly claims meeting with staff and upper management and performed employees appraisal evaluation ran daily report for management, developed new policies and procedure to enhance claims adjudication. Also, I attended quarterly board meeting performed system configuration on Rim 2.0 version and ran the month end reporting check write.

Education

Bachelor of Science, Healthcare Administration 2011University of Phoenix, Los Angeles, California

Associate of Science, Business Administration 1982CSUS, Sacramento, California

Associate of Science, Business Administration 1980Sacramento City College, Sacramento, California

3