SUMMARY:

Accomplished individual with outstanding and diverse skills used in the healthcare and health insurance industry include experience in system analysis, coding, claims, claim review, electronic claim processing, health record review, fraud detection, team lead, customer focused management, grievances and appeals, provider negotiating and settlement, and computer system conversions. Solution focused, analytical, detailed with clinical medical knowledge, involved in multiple entrepreneurial businesses including start up ventures, marketing and development of processes and procedures with a proven track record of increasing profits with measurable results.

HISTORY:

Confidential, NJ

Business System Analyst

Responsibilities:

• Creation, Design, Development and Implementation of a new repository of all products and benefit information creating a more efficient and accurate source of group, plan and benefit data.
• Business lead for multiple lines of business, constructed integration of Medical and Dental policies, integration and implementation of Healthcare Reform, verification of Medicare Benefits with CMS. End to end project implementation.
• Facilitated Requirement gathering; author documentation of requirements (document of understanding, business requirement documentation, and/or statement of work); analyzed downstream impacts; conducted impact analysis sessions; xml mapping to portals and contracts; deployment check outs; create test cases; system testing; traceability matrix; and user acceptance testing.
• Devised training courses to system training for user education; and produced User Manuals, coached users on system. Instrumental in Converting user remarks in legacy system into data models.
• Devised process flows to implement mandates, projects, and policy which was adopted based on my models. Mentored and trained additional personnel to team.
• The first 18 months associated with the project to build a product and benefit repository Product Administration Consultant in the capacity as business system analyst to enhance the company efficiency by creating a single data source for all non claim issues, which resulted in the development of a repository that houses products, benefits, sales entry tool and the customer service tool to provide members with detailed benefit information.
• The repository is linked to databases housing medical/dental policy, mandates, regulatory and filing issues.

Private Practice Management Consultant

Confidential

Responsibilities:

• Responsible for improving employee productivity, increasing accounts receivable and decreasing outstanding billable.
• Wrote procedure and protocol manuals specific to each practice.
• Ran training classes for employees of medical practice specific to their position and area.
• Trained and Managed billing coordinators on coding practices with proper use of coding ICD - 9, CPT, HCPCS and DRG to achieve optimum results, therefore increasing revenue and enabling the Billing coordinators to effectively negotiate with clients and insurers with measurable improvement.
• Assessed current computer system, analyzed current business practices with solution resolution for increasing efficiency, revenue, employee retention, maximum patients’ being seen and patient satisfaction.
• Decreased the time taken for claims submission, decreased patient waiting, and decreased customer/patient complaints.
• Implemented computer system upgrades with electronic medical records and physician use of voice recognition software.

Confidential

Practice Operations Manager

Responsibilities:

• From physician record of visit, Coded patient record and billing claims with proper CPT, IDC-9, HCPCS and DRG for optimum payment for multiple physician’s and locations, sent electronically daily for processing.
• Wrote company process and procedure manuals, wrote physician care manual with Medical Director, and wrote detailed and complex position manuals to be used in defining responsibilities for all personnel, implemented manuals in multiple offices.
• Verified insurance coverage for patients with Medicare and secondary insurer.
• Coordinated care with other agencies as prescribed by treating provider for patients.
• Assisted patients’ to receive discounted medication from pharmaceutical manufacturers.
• Backed up provider’s clinically when unavailable.
• Audited charts, ensured that billed work was performed.
• Solved problems as needed.
• Marketed the services to home health agencies, assisted living facilities, senior centers, and gerontology/family and internal medicine physicians.
• Prepared office payroll, documented employee evaluations.
• Responsible for weekly and monthly reports of census, RVU’s, profit and loss, practice budget per region by office.

Confidential

Practice Manager

Responsibilities:

• Trained and staffed front desk and managed front desk employees.
• Converted practice to Medical Manager PC based system, which included voice recognition and electronic medical records.
• Pre-certified patients with insurers for MRIs and CTs. Coded billing with proper CPT, IDC-9, and HCPCS for optimum payment.
• Scheduled appointments as needed.
• Marketed services of facility to area physicians. Increased amount of MRIs performed per day from 5 to 17. Handled all patient complaints.
• Managed accounts payable, and entered accounts receivable received by mail.
• Negotiated reimbursement with insurers.
• Prepared monthly budgets for owners of practice, prepared billing for billing agency by coding procedures and drugs, and prepared payroll.
• Solved problems as needed. Handled collections and purchasing.

Confidential

Case Management Claims Analyst Team Leader

Responsibilities:

• Responsible for multiple analysts placed at 4 insurance companies, for staff of 15 analysts, and for staffing.
• Coded billing with CPT, ICD-9, HCPCS, and DRG.
• Negotiated with providers’ contracts to decrease cost to insurer.
• Served as liaison for insurance companies, analysts and company.
• Audited analyst work for errors.
• Reviewed Liability and Workmen’s compensation cases.
• Reviewed billing from providers with medical records ensured billed work was performed. Solved problems as needed.