1. Stanley W. Robinson
8044 Montague Ct.
Glen Burnie, Md., 21061
Home 916-317-6410
stanrobinson2@yahoo.com
or 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.

2. 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 - 12/2009
Claims 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 – 12/2008
Sr. Claims Analyst
Processed 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 - 2007
Quality 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 - 2002
Claims 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
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3. 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 - 2001
Claims 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 - 2000
Claims 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 1994-1995
Claims 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 2011
University of Phoenix, Los Angeles, California
Associate of Science, Business Administration 1982
CSUS, Sacramento, California
Associate of Science, Business Administration 1980
Sacramento City College, Sacramento, California
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