- Professional with solid experience in managed healthcare organization and finance field. Have extensive knowledge, executing intensive projects with end goal vision. Employ fact based analysis, review root cause and develop solutions. Bond strong relationships and can positively influence people to achieve merits.
Advanced: Microsoft Excel, Word, Power Point, Outlook and Access, Share Point, Lotus and Macro Express.
Project Management tools: Clarity, Microsoft Project.
- Requirements gathering for database structure and internal integrated systems. Analyze client base data to ensure company’s compliance with case life - cycle turnaround times.
- Audit organization’s contracted timeline obligations and compliance with Medicaid and Medicare.
- Employ in depth knowledge with the use of broad integrated health care systems. Oversee member enrollment management and coverage determination policies.
- Actively involved in health data systems integration, performance, user acceptance testing and execution.
- Retrospective case management and ER visit trend analysis
- Retrospective claim reviews, authorizations and coordination of benefits
- Resolved member and provider financial complaints, in depth analysis of fact findings
- Processed in network and out of network billing
- Effective internal (senior leadership) and external (provider, member) communication
- End to end complex case research and resolution
- Knowledge of proprietary systems: LINX, ISET, IDT, QSTAR (quality systems), COSMOS,
- CARTA, ARTT, OIC
- Billing and collection for long term care insurance policies
- Responsibilities include full account maintenance for Metropolitan Life LTC, Genworth, AIG and other major insurance companies
- Draft and coordinate written responses to insurance policy holders requests (explanation of benefits, out of pocket maximums, co-pays, deductibles)
- Establish and maintain business communication with the individual clients
- Effective prioritization and utilization of resources in fast paced environment
- Assist with producing ad hoc reports and analysis