Sergio Velasco CV

Sergio [email protected] 12571 Wood Center Drive 904-451-9623

Experience

From 01- 2015 – present

Company: Aetna/TPA Doha Qatar

Quality Chief Officer

Manage TPA Quality operations for Qatar local Health Scheme, the duties of the Head of Quality Assurance Programs include:

Ensures administrative compliance with the Qatar National Health Insurance Scheme, including policy documents and guidelines issued by National Health Insurance Company and Supreme Council of Health (SCH).

Responsible for communicating new policy documents, and circulars to TPA team leads, documenting policy changes, identifying stake holders, escalating policy gaps, develop business requirement, steer procedural improvements targeted at complying with policies.

Building strong relationships and partnerships (SME’s) across the organization (rather than a more legal “Watchdog organization”), with Operations (Claims, Provider management), Audit and Recovery, OpEx, Medical Policy Department, Call Centre, Analytics, PMO, Communications, IT, HR, to effectively integrate ethics and compliance programs, standards and principles into the business.

Incorporate elements such as Oversight, chain of command, documenting processes and procedures, reporting investigations, enforcement, risk assessment (at the Regulatory, Compliance and functional level).

Training and Communication to help employees understand their role in the compliance function.

Develop, implement, support and promote Health Services strategies, tactics, policies and programs that drive the delivery of quality of healthcare in a cost effective manner. Health Services strategies, policies and programs, comprised of utilization management, quality management, network management, clinical coverage and policies.

Lead and manage all aspects of quality programs and projects that enable TPA to measure, monitor and improve the quality of its products, services and processes.

Achievements

Successful review of scheme guidelines to ensure that the program is correctly positioned, structured, and within the appropriate compliance guidelines.

Sergio Velasco

Led the development of an independent Team, to evaluate activities in the business units from compliance perspective, addresses centrally the reliability standards; and maintain an active ongoing conversation with regulatory bodies.

Led the implementation of the Overall Compliance Strategy, particularly with regards to Client/TPA relationship.

Managed the oversight of Company’s policies covering all areas to ensure all relevant procedural/legislative (SCH) requirements are followed.

Provided full assistance in the conduct of internal and external audit processes which will promote high standards of business controls, minimize risk exposure.

Reported on effectiveness of Quality Management initiatives and the impact of the communication campaigns in order to mitigate any confusion or misunderstandings

Counseled all TPA departments on initiatives (circulars, benefit schedule, benefits interpretation); which resulted in less Scheme’s ambiguity.

From: 2012-2014

Company: Aetna, Jacksonville, FL

Title: Executive Resolution Team Office of the Chairman, Project Manager

Manage Executive Complaints on behalf of the Chairman’s and its Direct Line of Reporting.

Responsibilities

Review and respond to Executive matters (via phone and/or correspondence), determine root cause, identify potential process gaps, provide a written response to the sender with an explanation of the consumer dissatisfaction origin, development of mitigation and action plans for all complaints. Additionally, monitored all Executive media cases, and facilitated meetings to resolve all complaints.

Achievements

Developed and Streamlined the process of handling Executive complaints (from an non-existing practice, to a well-structured and streamlined consumer model process)

Manage the Executive Consumer Experience project to improve the customer interactions with Aetna employees or representatives.

Involved in conceptualization of smartphone applications that helps customer to access service easily and quickly

Implemented enhanced quality improvements on simplified policy materials that are easily understandable by customers

Redesigning the handling “denied claims” - from assessment to denial stage. Designed “Escalation Protocols” that allowed irate customer to surpass the IVR (Interactive

Voice Recording) and reach floor supervisors/managers directly Removal of the Customer Service Average Handle Time (AHT) as an individual metric Successfully revised and modified call metrics current metrics, quality, coaching, and incentives

to incur desired behaviors. Responsible for ending complaints of no management call handling available for escalation (i.e., scheduled call back queue instead of holding).

Sergio Velasco

Implemented additional proactive modeling of potential escalations (root cause for repeat callers).

Other projects – Lead & Managed

Lead Contact for nation’s “my buddy” initiative. This initiative allows Customer Teams around the nation to review highly complex issues involving member’s health, finances, undue hardship, and medical care.

Lead Project Manager for the “Leaders without Borders” Project, in a short period; successfully implemented process improvement changes with a financial saving impact of over 1 million dollars in savings for 2015 operations budget.

Lead contact for the Health Operations Policy Process Committee, leading with highly complex and diverse policy matters.

Additional Experience

From: 2008-2012


Title: Complaints and Appeals – Manager

From: 2006-2008


Title: Supervisor, Customer Service

From: 2004-2006


Title: Provider Data Services Consultant

From: 2000-2004


Title: Claim Reporting & Specialty Services Consultant

Education

University of Phoenix -Bachelor in Business Management

Sergio Velasco

Six Sigma Green Belt

Languages: Fluent in Spanish (written and verbal) limited French.

REFERENCES AVAILABLE UPON REQUEST

Documents

Sergio Velasco CV