Karen Dukes
Doylestown
Summary
Results-driven project coordinator with a strong focus on process optimization and compliance analysis. Proven ability to streamline operations and enhance workflow efficiency in multi-departmental projects.
Overview
27
27
years of professional experience
Work History
Plan Coordination Consultant
Aetna, a CVS Health
Woonsocket
10.2018 - Current
- Coordinated multi-departmental projects, enhancing plan implementation processes to improve efficiency.
- Documented workflows and processes to ensure streamlined operational management.
- Ensured compliance with laws, regulations, policies, and procedures in all activities.
- Maintained comprehensive records to support effective plan coordination and operational oversight.
- Managed multiple projects simultaneously, ensuring timely completion within budget constraints.
- Identified and recommended improvements for existing plans and processes to enhance overall effectiveness.
- Assessed client feedback on plan coordination to pinpoint improvement opportunities.
- Reviewed project requirements, providing feasibility feedback on proposed solutions.
Eligibility Specialist
Aetna, a CVS Health
Blue Bell
10.2006 - 10.2018
- Evaluated eligibility for health care benefits and services based on established criteria.
- Reviewed applications for accuracy and compliance with program policies, ensuring adherence to eligibility standards.
- Collaborated with cross-functional teams to address and resolve eligibility issues.
- Maintained detailed records of member interactions and eligibility determinations to support program integrity.
- Assisted in training new staff on eligibility processes and system navigation.
- Ensured comprehensive knowledge of program regulations, policies, and procedures.
- Verified client information through thorough review of applications, resolving discrepancies to ensure accurate eligibility assessments.
Senior Claims Examiner
AmeriHealth Administrators
Fort Washington
10.1998 - 10.2006
- Evaluated insurance claims for accuracy and ensured compliance with company policies, enhancing claims processing integrity.
- Reviewed medical records to assess claim validity and ensure appropriate payment levels.
- Analyzed documentation to determine eligibility for coverage and benefits.
- Coordinated with legal and underwriting teams to manage dispute resolution, facilitating timely and fair claim settlements.
- Verified and analyzed claims settlement data for validity, supporting accurate financial reporting and compliance.
- Provided training and mentorship to junior examiners on claims evaluation best practices.
- Supervised independent adjusters to ensure adherence to guidelines.
- Maintained up-to-date knowledge of healthcare reform legislation affecting provider reimbursements.
Education
Temple University
Philadelphia, PASkills
- Project management
- Compliance analysis
- Healthcare regulations
- Risk assessment
- Policy review
- Policy implementation
- Process optimization
- Data management
- Data analysis
- Data governance
- Strategy development
- Workflow documentation
- Continuous improvement
- Customer relationship management
- Cross-functional collaboration
- Effective communication
- Teamwork and collaboration
- Attention to detail
- Time management
- Multitasking capacity
- Adaptability to change
- Problem solving
- Goal setting
- Healthcare experience
- Professionalism
- Data governance
Timeline
Plan Coordination Consultant
Aetna, a CVS Health
10.2018 - Current
Eligibility Specialist
Aetna, a CVS Health
10.2006 - 10.2018
Senior Claims Examiner
AmeriHealth Administrators
10.1998 - 10.2006
Temple University