MYRA L. SMITH8810 Sonny Boy Lane Apt. 3203Pensacola, Florida 32514 (850) 516-6782msmyralsmith96@hotmail.com

Professional Summary: Goal-oriented and results-driven professional with over 10 years experience in Healthcare Management with focus on Medicare, Medicaid, Managed Care, Appeals and Grievances, and Practice Management Government audits such as HEDIS and PERM.

PROFESSIONAL EXPERIENCE

MCKESSON BUSINESS SOLUTIONS, Pensacola, Florida 10/2010 – Present

Sr. Quality Review Analyst, Operations 06/2013 Review and analyze reimbursements for accuracy in accordance with organizational and Federal guidelines and mandates. Conduct data analysis and promulgate report findings to Executive management for process improvement and trending

analyses. Collaborate with Compliance as a committee member to review and submit information pertinent to Government and internal

audits. Managed Care Operations, Claims Supervisor 10/2010-06/2013 Monitor operations to ensure adherence to departmental standards including productivity, financial, and data accuracy rates. Coordinate communications between provider offices and customer service department regarding claim payment and denial

issues. Analyze physician administrative appeals and provide recommendations for improvements to senior management.

ACCUSTAFF, Pensacola, Florida 06/2010-10/2010

Front Desk Receptionist Monitored and documented visitor safety measures. Filed safety and confidentiality affidavits signed by all visitors. Answered and transferred incoming calls.

UNIVERSAL AMERICAN, Houston, Texas 05/2002-06/2010Appeals and Grievances Quality Manager Monitored compliance and quality management efforts to support accreditation and regulatory objectives. Trained and mentored staff on the Center for Medicare and Medicaid Services guidelines and regulations as pertaining to

Medicare Advantage and Part D health plans. Analyzed and reported trends regarding appeals and grievances.

Appeals and Grievances Manager 10/2007-01/2009 Supported and communicated with network operations, providers and vendors regarding care coordination, access to quality

care, and resolution of members’ appeals and grievances. Monitored the timeline and processing of all appeals and grievances regarding The Center for Medicare and Medicaid Services

guidelines. Researched and presented findings to the Quality Improvement Committee all appeals and grievances trends.

Appeals and Grievances Supervisor 06/2005-10/2007

Subject Matter Expert on guidelines for Appeals & Grievances as dictated by the Center for Medicare and Medicaid Services. Coordinated efforts for appeals and grievances as pertinent to Part D Operations. Supervised and trained employees on processing complaints received through the Center for Medicare and Medicaid Services

Complaint Tracking Module. Implemented a successful training program for new hires. Liaised with Governmental staff to discuss and resolve complaints.

Promoted teamwork within the department and ensured excellent customer service standards were met. Communicated findings and status updates on complaints to senior management.

Agent Licensing Representative 05/2002-06/2005

Assisted Insurance brokers and applicants through the hiring process Conducted local and state background checks for applicants

Mentored and trained new employees on departmental processes and workflows.

EDUCATIONCurrently enrolled Pensacola State College Pensacola, Florida

Healthcare Management2009 – 2010 Houston Community College Houston, Texas

General Studies

COMPUTER SKILLSProficient with the use of Trizetto Facets and Microsoft Office Suite products.