PAMELA S.

JACKSON
Frederick, MD 21702 301-668-9274 Pjackson21702@yahoo.com

SUMMARY
Results oriented Healthcare Services Professional with extensive and diversified experience within Managed Care, commercial, and government sponsored healthcare programs and products. Expertise in claims and adjustment processing, project management, call center management, provider relations, contract review and set up, startup operations, and process reengineering. I have worked for two regional trauma service hospitals, a Fortune 25 health services company as well as a smaller, regional health plan. I have proven results in problem solving, relationship building and provider retention. I am an innovative thinker and strategic planner with demonstrated abilities in leading and developing high performance teams. Project Management, claims systems Operations and Call Center Management Health Maintenance Organization/Capitation Creative Problem Solving Polished trainer and public speaker Mentoring and Coaching Relationship building Revenue Cycle Management

EXPERIENCE
UnitedHealthcare, Rockville, MD 2010 - 2013 Director Network Operations Mid-Atlantic Region (2010-2013), Directed decommissioning activities for an acquisition claim system. Managed Gated HMO products by engaging corporate stakeholders to facilitate issue resolution and prevention. Project Manager for provider data cleanup initiatives, capitation system migration, standardization of authorization requirements, and a multitude of claim system enhancements. Managed a system realignment process for Gated HMO membership and providers; moving them from Health Plan oversight to align and merge them under the direction of corporate authorization, claim and appeals departments. Participated in a Six Sigma project to increase employee productivity resulting in an FTE reduction of 33%. Consultant to the Six Sigma Project Managers responsible for claim and service process improvement and regulatory compliance. Mentor, trainer, and subject matter expert for regional hospital, physician, ancillary advocates and network contractors across the Mid-Atlantic and Northeast Regions. Coordinated provider communications, including Administrative Guides, mailings, training materials, and event notifications. Director of Operations and Provider Relations, Mid-Atlantic States (2006-2010) Directed service initiatives related to large hospital systems and regional ancillary providers across the MidAtlantic. Increased satisfaction levels of participating providers through the implementation of an Advocacy program. Led the Northeast/Mid-Atlantic Advocacy work group responsible for the identification of systemic problems, educational needs, and work flow redesign opportunities. Expanded and accelerated the roll out the Hospital Relations Model in Maryland, Delaware, DC and Virginia. Orchestrated the design and implementation of an internal team dedicated to claim resolution and root cause analysis that supported providers and UHC Advocacy staff. Managed the Gated HMO product on multiple system platforms. Incorporation of service responsibilities for Medicare plans and two Medically Managed Gated HMO plans. Recruited and trained an Advocacy team with members who either telecommute or are based out of office locations across the service region. Engaged with hospital and physician organizations including MGMA, AAHAM, and state Medical Societies

PAMELA S. JACKSON, Pjackson21702@yahoo.com

PAGE 2

Managed multiple internal and external projects, including overpayment recoveries, and new product implementations. Mid-Atlantic Medical Systems, Inc. (MAMSI), Rockville, MD 1990 2006 Senior Director Claims Operations Held multiple positions throughout the organization. The company underwent a period of very rapid growth. Able to respond quickly and adapt to the ever changing environment. Most notable contributions include: o Expansion of Hospital Bill Auditing Program. This yielded an approximately 3% savings on claims that were audited. o Designed and implemented ER chart reviews by RNs to improve PCP satisfaction. o Implemented a Clinical Review Unit, staffed by RNs, to supplement the cost containment unit. This resulted in over $10 million in savings to the company. o Established the high-dollar claim review process which prevented high-dollar claims from being paid in error or to pay on errors within the claims. o Data mining to find overpayments, determine root causes and work toward system fixes. o Established relationships with all of the various departments within the company and served as a claims department representative / Subject Matter Expert. o Provider visits to Tier1 and high-profile providers/groups/hospitals. Worked with various teams to resolve issues and improve provider experience. o Supervised call center, claims examiners and claims auditor groups. o Instituted contract reviews and recommended changes to yield savings to Health Plan. This resulted in more consistent contract negotiation strategies. o Worked on various teams to implement new Utilization Management or Health Plan policies. Interfaced with multiple internal and external stakeholders. o Represented MAMSI in various court proceedings (local as well as Federal courts) o Completed chart and claim reviews and overall policy applications for outside counsel. o Worked with inside counsel for selected matters at the Maryland Insurance Administration and Office of Administrative Hearings.

OTHER RELEVANT EXPERIENCE

Suburban Hospital, Bethesda, MD Head Nurse, Emergency and Trauma, Managed 24/365 clinical operations of the ER and Trauma Department Overall responsibility for 97 FTEs. Recruited, hired, and evaluated RNs, LPNs, and ER Technicians. Mentored and coached clinical management team. Managed Administrative functions for the Emergency and Trauma Unit, including such items as budget preparation (capital and operating), monitoring and adjusting for budget variances regular reports to both the physician operation and nursing administration.

Washington Hospital, Washington D.C, Assistant Head Nurse, Emergency Nursing Managed RNs, LPNs, and ER Technicians for the Evening Shift at a Tier 1 urban hospital with 100,000 visits per year.

EDUCATION
Master of Business Administration, Mount Saint Marys University, Emm itsburg, MD Bachelors of Science Degree in Nursing Bowie State College, Bowie MD Nursing Diploma, Washington Hospital Center School of Nursing, Washington, DC

CERTIFICATIONS
Certified Legal Nurse Consultant, Vickie Milazzo Institute 2001