- Versatile, adaptable, and solution-driven professional with an extensive background in the product administration of commercial and government health plans including Medicaid, Medicare, FEHBP, HSAs, Managed care products, et al , healthcare IT solutions, healthcare information management, and related academia in analytical, training, and leadership roles.
- Recognized ability to convey subject matter to diverse audiences, to quickly learn new and complex applications to provide immediate contribution, and to embrace team efforts in joining together disparate knowledge bases to share, grow and collaborate to fulfill both short and long-term strategic missions.
- Constant learner and active listener who embraces dynamic environments, new methods, approaches, and business intelligence tools to better understand, analyze, and report information and to broaden the technological resources of an organization.
Provide tutelage, coaching, and mentoring for clients for a broad range of disciplines including biological, chemical, and physical sciences, mathematics, statistics, Java, English composition, and preparation for post-graduate and certification-level exams.
- Created ICD-10 training material to include both a traditional didactic program and a medical-surgical modular approach to address nursing and allied health students' needs to refresh and expand their clinical knowledge for the more rigorous and expansive coding guidelines.
- Instruct clients in the set-up, navigation, and use of open source software as preparation for many of the databases/programs/applications that they will be using in an enterprise-wide environment.
- Established an extensive customer base by adhering to a mission founded on flexibility, accessibility, integrity, and reliability.
- Medicaid Business Analyst/ Operations Management Functional Lead Health Human Services Division
- Worked within a matrix organization on the design, development, and implementation project for South Dakota's new Medicaid Management Information System MMIS . Researched all RFP requirements for the business processes of Reference Data Management, Claims Receipt Adjudication, Program Integrity Management, Pharmacy Benefits Management PBM and Third Party Liability TPL . Notable:
- Served as subject matter expert for Medicaid, healthcare claim data, the claim cycle, and CMS regulations to assist colleagues new to the healthcare domain with RFP analysis and timely completion of SDLC deliverables.
- Attained mastery of the organization's Medicaid system, associated modules, and business rules engine within weeks of arrival to give both high-level/Q A presentations and system demonstrations.
- Analyzed RFP specifications and conducted gap analyses from a Medicare Information Technology Architecture MITA perspective to research solutions for end user processes and graphical user interfaces GUIs to be added or enhanced/reengineered in order to meet to be functionalities.
- Ensured MITA maturity model alignment during requirements validation met CMS Medicaid Enterprise Certification Toolkit MECT items and updated the Requirements Traceability Matrix RTM accordingly.
- Captured logical flow of business processes through flowchart mapping and use case development to provide the functional requirements documents to developers working within an SOA framework.
- Led Joint Application Development JAD sessions with the technical lead and software developers to ensure compliance of system design with new system functions, user interfaces, and reporting requirements.
Senior Contract Analyst
- Analyzed and reported on metrics for cost-management, utilization rates, charge capture, payment integrity, and clinical outcomes for the 20 hospitals of the UPMC Health System. Provided data analysis and reporting support during contract negotiations. Notable:
- Gathered business requirements from clinical staff and other stakeholders to generate the functional and technical requirements for developers to modify and enhance decision support software.
- Served as liaison to the Information Systems IS department to review system design solutions for the integrity of rate calculations and to test new pricing methodologies prior to final implementation.
- Led JAD sessions with IS department leads and the decision support software vendor to resolve outstanding issues and to optimize use across corporate business units and hospital clinical departments and to resolve issues discovered during implementation and maintenance of the software.
- Eliminated paper-based records through the creation and maintenance of a departmental database to store, analyze, and report on current and past payer contract data.
- Developed a structured ETL process for updating hospital data.
- Researched and provided solutions for all payment discrepancies discovered through expected versus actual reimbursement comparison reports.
Conducted audits and researched payment issues for all contracted hospitals, ambulatory surgical centers, skilled nursing facilities, imaging centers, and large physician groups. Created fee schedules based on medical service categories e.g., radiology, laboratory, surgery, etc. and their corresponding CPT/HCPCS codes. Updated internal systems for new/revised provider contracts. Provided reporting support during annual NCQA/HEDIS reviews and during provider contract negotiations.
- Developed and implemented a comprehensive internal audit process which led to a reduction in payment errors and a renewed focus on process and payment integrity.
- Updated and maintained all hospital and large physician group rates DRGs, APCs, ASCs, biologics, outpatient service categories, etc. and rate calculation formulas based on individual contract agreements while ensuring compliance with CMS reimbursement updates to ensure the integrity of all payment arrangements.
- Enabled the recovery of overpayments associated with the upcoding of evaluation/management E/M codes found through procedure-specific report results.
- Served as primary liaison with both the dental and hearing benefit vendor partners in resolving all member complaints, authorization issues, and member financial responsibilities for dental and hearing services.
- Assisted the marketing department in the development of Medicare Part D educational materials both for customer service representatives and for member-mailed informational documents.
- Recommended cost-saving measures from the analysis of SQL-derived healthcare claim data and trending data of claim submissions, billed procedure frequency, and other metrics leading to a reduction in overpayments and an increased awareness on potential fraudulent billing.
- Disseminated educational material regarding proper billing practices, CMS updates, and other contractual matters for provider service representatives to discuss and resolve with their assigned providers.
Provided analytical and reporting support in the administration of health insurance products for high profile NYSE/NASDAQ clients while providing leadership to a 25-member administrative team. Extracted and analyzed data in the resolution of system and manual issues affecting all stages of the healthcare claim cycle. Designed and created reports for inventory control, change-request tracking, staff development, and fraud detection. Served as adjudication system subject matter expert for departments throughout the organization. Served as primary liaison with the behavioral health vendor. Liaised between end users and software development teams.
- Enabled substantial financial recoveries through routine analysis of adjudication records, ERAs, EOBs, and targeted SQL reports leading to the identification and recovery of substantial overpayments from programming errors/system defects.
- Established process improvement initiatives and payment integrity measures leading to an increase in claim processing timeliness by 30 and a reduction in adjustment inventories by 50 within eight months.
- Created a comprehensive internal auditing strategy that became the standard for adoption across all operational units.
- Achieved a 30 decrease in the number of open issues in less than two years through problem-solving strategies and continuous quality improvement measures.
- Appointed as the lead analyst in providing all data, reports, and procedural documentation for internal and external healthcare audits to ensure compliance and maintain accreditation with NCQA/HEDIS standards.
- Led SQL training sessions for other analysts in the proper construction of commands and syntactical statements to retrieve the most useful and actionable data.
- Assisted the Special Investigations Unit with data analysis and case compilation in the identification of fraudulent billing practices.
- Authored uniform and user-friendly end user documentation to ensure adherence to policies and procedures related to the manual adjudication of suspended claims.
Researched and provided resolution for issues affecting accuracy of claim adjudication system output. Conducted training sessions for system end users administering both commercial and government health insurance products. Developed and tracked the success of quality improvement initiatives. Created corrective action plans to promote benefit plan adjudication accuracy and to ensure process and payment integrity. Authored end user documentation for system applications, subrogation/coordination of benefits calculations, and drug/pharmacologic conversions.
- Participated on a multi-year system migration project within a cross functional team devoted to the testing through implementation phases of the SDLC for all managed care products in a newly adopted claim adjudication system.
- Healthcare Information Management, Technology, Legislation Summary
- CMS regulations/policies/pricing, ARRA, COBRA, ERISA, HIPAA, HITECH, PPACA, PQRS, et al , NCPDP standards, Project management methodologies, Healthcare coding/billing including CPT, E/M, HCPCS, ICD-9, ICD-10, Revenue codes, OCE, NCCI and private vendor code edits, CMS 1500 and UB04 data elements, et al , Reimbursement methodologies including FFS, Capitation, Pay-for-performance, IPPS, OPPS, RBRVS, RVUs, APCs, DRGs, et al , EHRs Meaningful Use, HL7 interoperability standards, ASC X12 ANSI Version 5010 EDI transactions, RDBMS, MS Office Access, Excel, PowerPoint, Word , MS Outlook, MS Project, Object-Oriented Analysis Design, Visio, BPMN, UML, SharePoint, Decision support software, Java, SQL.