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Denise J.

Operations Manager | Healthcare


Healthcare Operations Director with expertise in employee benefits programs and how clients access healthcare and wellness opportunities. A deep understanding of the cycle of benefits from client enrollment to care, coverage, and claims.

Able to identify root cause issues and improve processes. Working in a union environment and at a healthcare clinic, persuasively influences external and internal stakeholders to reduce waste and eliminate barriers to care access.

Key Skills & Competencies

• Program Design - Created an employee wellness plan with benefits and health incentives in 30 days, at a very low-cost.
• Employee Engagement & Retention – Incorporated WhatsApp Business to increase engagement with home health aides.
• Population Health Program Development –Analyzed population health and integrated Social Determinants of Health (SDOH) in the strategic planning of Patient Centered Medical homes and surgical bundle programs, improving patient outcomes.
• Tech-Savvy Process Improvement – Streamlined processes by implementing an Access database that integrated eligibility system and claims history to eliminate toggling in multiple systems.
• Problem Solver/Negotiator – Identified an exposure on certain types of claim reimbursements for clinic visits and navigated managed care re-negotiations saving money and leading to changed policies.

Benefits Administration | Employee Retention | Health Initiatives | Policy Development | Healthcare Delivery
Regulatory & Compliance | Provider Services | Authorizations | Quality Assurance | Strategic Planning
Data Analysis | Team Leadership | Vendor Management | Cross-functional Communicator | Claims Review | Project Management

Access, Adobe sign, ADP, Asana, Centervue phone and auditing systems, Cisco AnyConnect agent and Supervisor system, Cisco unified historical reports, CRM, Docusign, eClinicalworks, MedOffice, Microsoft 365, MS word, excel, Microsoft Teams, QlikView, RP navigator, Sharepoint, Verisk, WebEx, Zoom, Managed care systems: Empire Blue Cross & CIGNA

Professional Experience

Health services offering family medicine, urgent care, adult day care, behavioral health, diabetes management, dialysis, and home health.

Director of Employee Health
Hired to implement and administer an employee benefit program targeted at improving employee well-being. Within 30 days, designed a low-cost suite of benefits that increased employee job satisfaction. Programs served 3,000 employees including physicians, medical assistants, adult day-care workers, administrative staff, and home health aides.
• Identified and mapped out how to offer telehealth services provided by Doral practitioners to fellow employees.
• Collaborated with communications team to create scheduling platform for employees to arrange free telehealth visits.
• Benefits encompassed free and convenient health services, health awareness, access to discount programs and fitness services, resulting in reduced burnout, improved job satisfaction, and retention.
• Achieved homecare worker wage parity by implementing an additional benefits package saving employees out-of-pocket health expenses and the company $3/hr on every home health employee.
• Project managed the creation of the benefits website with the communications team and provided all benefits content.
• Incentivized Chronic care and Remote Patient Monitoring programs.
• Designed and implemented a fitness health initiative with discounted gym memberships and regular fitness challenges.
• Administered gift card incentives to employees engaged in fitness challenges.
• Increased engagement of home health workers by changing communication delivery to WhatsApp Business.
• Presented benefit program specifics to 20 employees at a time in new hire orientations to encourage engagement.
Organization administering the health benefits of 250k lives of SEIU Local 32BJ.
Contracted Patient Centered Medical Homes: NY- Union Health Center, Institute for Family Health, AdvantageCare Physicians, WestMed, Crystal Run Healthcare, CT -ProHealth, NJ-Summit Health, Avenel Iselin Medical Group, PA-Geisinger, MD/VA/DC-Kaiser Permanente

Operations Manager - Health Fund | 4 yrs
Progressively promoted to managing health fund operations and ensuring SEIU 32BJ members received the best possible healthcare and navigated their benefits successfully. Oversaw the busy member call center operations and supervised a team of eight patient advocates, one assistant supervisor, and one RN responsible for negotiations.

• Supported the four Directors of the Health Fund by providing data reports and strategic recommendations for benefits changes prior to Board of Trustees Reviews.
• Provided background and recommended solutions to Compliance Team and Board of Trustees, for fair and compliant resolution to appeals and grievances.
• Built strong relationships on all sides of healthcare delivery to problem solve for: providers, union members, families, healthcare system issues, and case management.
• Leveraged cross-functional expertise to identify root cause of issues in a timely manner.
• Led patient advocate team from interview and hire, through training and people management. Average team tenure 5+ years and zero turnover with the exception of one retiree and one terminated employee.
• Conducted annual Performance Management, progression reviews and provided professional development.
• Identified areas of continuous process improvement, mapping workflow and process pain points to find the right technology solutions in collaboration with quality improvement team. Provided data input and model testing feedback.
o Result: Reduced team’s research and documentation task time by 3 minutes per call, by collaborating with database team to integrate the information used in three different systems into one Access database.
o Result: Trained and ensured SOPs were accessible within the database which also reduced toggling between systems. Simplified process for chronic care programs, integrating eligibility and claims history at point of enrollment.
• Maintained 3rd party vendor relationships necessary to resolve non-standard claims, authorizations, medical policy discrepancies, and benefit design issues.
• Reviewed and updated annual summary plan description booklet and Summary Benefit Changes for accuracy and clarity.
• Implemented surgical and wellness programs for members (incentives ex; transportation, Grocery Gift cards and no copays). Analyzed data to determine enrollment targets, measure performance, and improve operational outcomes.
• Provided resolutions for claims or provider credentialing issues with contracted Patient-Centered Medical Homes and other external healthcare professionals.
• Collaborated with cross-functional teams (Member Services, Pension, HR, Executive Office, Union, Employee Services, and Enrollment & Eligibility) to improve process and ensure efficiency in servicing members.
• Shared expertise with Analytics team to spot root causes in data analysis to determine definition of an episode of care.
• Identified gaps in authorization process and updated accordingly to align with benefit design or supported denials.

Supervisor, Medical Management Department | 2 yrs
Supervised a strong team of eight Patient Advocates who maintained a 90%+ average on phone audits while helping Union Members and their families navigate the healthcare system.
• Reorganized Call Center teams by creating career pathing for Triage Coordinators and designing new Patient Advocate role.
o Retained all team members and improved employee satisfaction with union-approved pay grade increase.
o Communicated the change with SOPs, trained and transitioned 8 team members, improving productivity.
o Audited new processes and closed gaps which allowed innovation and smooth adoption of new roles.
o Conducted quality audits.
• Collaborated with the health fund team to implement surgical bundles and Chronic Care programs that cut costs and provided members with the option to receive coordinated care.
o Based on cost analysis of high utilization services, developed specialty bariatric and joint replacement programs with incentives to members like transportation, nutritional assistance, and removal of copays.
o Provided individuals with Chronic conditions the option to receive quality coordinated care by contracting with Patient Medical Centers homes in which members incentives were no copays and prescription discounts.
o Created monthly report identifying prospective candidates for services and transitioned people into the program.
• Hosted regular Health Services team meetings to resolve patient centered medical home issues.

Supervisor Triage Coordinator, Medical Management Department | 6 yrs

Community Experience


Master of Healthcare Administration & Management (MHA), University of Phoenix
Bachelor of Business Administration (BBA), Healthcare Systems Management, Metropolitan College of NY

Project Management Certification, Google (completed 4 of 6 modules) | expected Fall 2023
Value-based Care Specialization Certification, University of Houston/Coursera (completed 4 of 7 courses) | expected Fall 2023

Other Experience/Awards/Publications

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