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Senior Clinical Provider Auditor Resume

SUMMARY

  • She is an experienced healthcare professional dedicated to reducing cost inefficiencies and improving healthcare data quality.
  • Solution driver possessing a unique combination of (strategic), technical and business acumen, she is healthcare industry expertise spans Payer, EHR Software Vendor, Pharmacy Benefits Manager with an emphasis on commercial and government programs (Medicaid), insurance, data warehousing/stewardship, program development, and data analysis for fraud, waste and abuse detection.
  • Led data integration project with large insurance company and PBM
  • Program Director to the Offices of the Attorney and Inspector General
  • Led the MITA (Medicaid Information Technology Architecture) State Self - Assessment program
  • In-depth knowledge of healthcare data quality challenges and strategic solutions
  • Provided project management and lead data analyst oversight of technology and business teams in litigation against large drug manufacturer

PROFESSIONAL EXPERIENCE

Confidential

Senior Clinical Provider Auditor

Responsibilities:

  • Implementation and management of Quality Assurance program. Designed, created and manage SharePoint auditing tool to provide Internal Audit and management with accurate, efficient, detailed reporting. Create and maintain supporting documentation to ensure program continued compliance.
  • Prepare daily inventory reports synthesizing analytic results, highlighting implications of findings. Follow through any further action based on the results using sound business judgment.
  • Analyze and transform data leveraging tools such as Excel, SORDS Reports, and Pega CRAV (Coding Review and Validation). Participate in routine management discussion for metric performance.
  • Led solution design and development of internal SharePoint meta-data/knowledge repository site by integrating data from three legacy sites and collaborating with key departmental staff to gather business requirements. Subsequently designed and created additional sub-sites to meet staff needs. Serve as SharePoint administrator.
  • Manage training program supporting leadership and all commercial associates (geographically disbursed team of 100+ associates). Create and manage training materials including recording and producing on-demand training videos, providing associates access to critical information in the flow of work when they need to solve a specific challenge.

Confidential

Clinical Analytics Operations Data Mining Manager

Responsibilities:

  • Managed a team of data analysts and developers responsible for identifying potential savings for sixteen State Medicaid RAC (Recovery Audit Contractor) clients.
  • Researched CMS (Centers for Medicare & Medicaid Services) and local, client specific billing and reimbursement policies (for both commercial and Medicaid RAC clients), client specific MMIS (Medicaid Management Information System) systems and various claims adjudication data warehouses to develop and configure improper payment analytics.
  • Engaged with Medicaid RAC clients, Executive Management and additional stakeholders to communicate analytics results and design strategy to reduce client risk for revenue loss.
  • Identified the business need and led the effort to cleanup data inconsistencies across internal interfaced applications for analytics, and reporting purposes.

Confidential

Senior Fraud Data Analyst/Quality Assurance Team Lead

Responsibilities:

  • Led Quality Assurance team, ensuring all departmental goals were met/exceeded.
  • Engaged in client-facing role supporting Program Managers as subject matter expert in quality data analysis processes, policy research, current data analytics and recommended data analytics in support of five State Medicaid plans.
  • Identified, data mined, analyzed, and categorized potential fraudulent claims.
  • Collaborated with the Operations team to create policies, procedures and cross-functional database reconciliation reports designed to guide day-to-day operations and help reduce risk for revenue loss.

Confidential

Business Analyst

Responsibilities:

  • Led the e-prescribing certification project with Surescripts. This effort included overall project management, quality assurance coordination, First Data Bank (FDB) data profiling.
  • Collaborated with Senior Staff and Product Managers in Agile/Scrum development methodology environment to create an online electronic health record product.
  • Analyzed and ensured product enhancements were documented and implemented to meet or exceed CMS (Centers for Medicare & Medicaid Services) Meaningful Use for EHR (Electronic Health Record) and HIT (Health Information Technology) policies requirements.
  • Served as metadata repository steward for an internal-use database housing the following industry standard codes: SNOMED (Systemized Nomenclature of Medicine), CPT (Current Procedural Terminology), ICD-9-CM (International Classification of Diseases.
  • Created design and development specifications and program functions using Adobe InDesign C5.
  • Exercised independent judgment to solve challenges inherent in software application design and development.

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