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Medicare Analyst Resume

Birmingham, AlabamA

SUMMARY

  • Healthcare Consultant with experience in the Managed Care Industry utilizing Project Management Methodology.
  • Experience working with a Conglomerate of Software Applications and Operating Systems.
  • Demonstrated ability to learn tasks quickly, analyze data and understand relationships.
  • Ability to effectively handle multiple projects simultaneously and give individual attention and details to each with priorities on excellent quality, task management, time management and completing projects within required deadlines.
  • Experience working with several lines of business including but not limited to EPO, HMO, PPO, Confidential ITS, Medical, Dental, Vision, Pharmacy, Medicaid, Commercial Health, Original Medicare, Medigap and Medicare Replacement Plans (Medicare Advantage - Medicare Part C).
  • Excellent leadership and Project Team Building skills.
  • Seeking a position that will utilize my experience, skills and knowledge as a viable resource who will contribute to your company’s profitability and success.

PROFESSIONAL EXPERIENCE

Confidential - Birmingham, Alabama

MEDICARE ANALYST

Responsibilities:

  • Educate providers on the Centers for Medicare & Medicaid Services Guidelines for claims, Medicare Part B benefits and all Medicare Part B services.
  • Provide Callers with specific benefits requested for Medicare Part B Beneficiaries.
  • Verify Beneficiaries Medicare Part B Eligibility and Entitlement details.
  • Assist providers with the reason why their payments for Original Medicare claims were denied.
  • Gives details regarding Medicare Secondary Payer (MSP), Coordination of Benefits (COB) and Medicare not eligible services due to Member’s Medicare Replacement Plan Enrollment.
  • Instruct providers how to submit claim denial First level Redetermination Appeals and subsequent Second and Third level appeals if warranted.
  • Advise providers in detail the reason for their Medicare Payment Offset and Refunds Requests.
  • Answers provider’s questions regarding their Remittance check numbers and payments discrepancies.
  • Advised providers how to dispute and submit Medicare appeals regarding refund requests.

Confidential - Edison, New Jersey

MEDICARE ANALYST

Responsibilities:

  • Verified member dual eligibility in New Jersey Medicaid and Medicare Parts A and B.
  • Ensured that Medicare Advantage membership enrollment was in sync by reconciling CMS enrollment records and Horizon enrollment records.
  • Reviewed Daily Transaction Reply Reports (DTRR) and the Monthly Membership Reports (MMR) while abiding by Federal Centers for Medicare and Medicaid Services guidance (CMS).
  • Processed D-SNP applications for enrollment received via Paper with Field Sales Agent assistance, Telephonic, Web, iPad, CMS Portal and OEC - Online Enrollment Center submissions received via Facets Enrollment Administration Manager Workflow (EAM) system.
  • Reconciliation of all daily, weekly and monthly Medicare reports generated from CMS.
  • Researched and resolved enrollment discrepancies identified as a result of company and MMR report and Horizon records.
  • Directly responded or supported a response to inquiries that were rapid and professional to internal and external customers, not limited to Medicare Beneficiaries, Federal Regulators, Executives and Congress persons.
  • Generated and ensured compliance and accuracy of various types of member correspondence specific to retroactive enrollment submission to CMS.
  • Called potential subscribers and sent letters to verify membership, enrollment, billing and demographic discrepancies received on applications.
  • Updated beneficiary requests for enrollment of premium withholding.
  • Ensured monthly that all identified discrepancies resolutions were met with CMS timeframes.
  • Prepared case documents for retroactive enrollment updates.
  • After completion of Quality Assurance (QA) review released completed applications to CMS as an EAF - Electronic Application File.
  • Submitted applications via TriZetto’s Medicare Solutions Enrollment Administration Manager - EAM systems into CMS’ Batch Eligibility Queue - BEQ.
  • Made appropriate CMS guided corrections to insure approval and eliminate eligibility discrepancies.
  • Verified Member Enrollment and Benefits with the TriZetto MMS process of Facets Group, Subgroup, Class/Plan, Product and Subscriber/Family applications.
  • Corrected Beneficiaries application enrollment errors revealed via CMS MaRX, CMS Mismatch Report and CMS Discrepancy Report.
  • Audited D-SNP Enrollment Applications Processed by TriZetto, Facets 5.3.

Confidential - Chicago, Illinois

HEALTHCARE INSURANCE CONSULTANT

Responsibilities:

  • Processed facility and professional Medicaid, Medicare and Medigap claims according to DST/ Gateway and CMS guidelines.
  • Adjudicated Durable Medical Equipment (DME), Anesthesia, Member Not Covered and Provider not found, Radiology, Lab, Pathology, Physical Therapy, Occupational Therapy, Speech Therapy, Chiropractic and Home health claims.
  • Manually applied interest to claims paid after the 30 days maximum processing period.

Confidential - Birmingham, Alabama

Benefit Configuration Analyst

Responsibilities:

  • Used Benefit Maintenance to xPression (BMX), xPression Revise the Oracle EMC2 xPression Enterprise Edition to host the template and combine supplied large amount of data with the template to create documents Summary Plan Descriptions (SPD) - Benefit booklets.
  • Created Merit, Cost Plus and Flexible Spending Group Health and Dental Summary Plan Descriptions (SPD) - Benefit booklets.
  • Programmed changes to adjudication tables to ensure accurate and timely pharmacy claim payments.
  • Documented pharmacy language in Benefits Online (BOL) for internal, external associates and providers on the company’s website Bcbsal.org.
  • Analyzed and implemented corporate benefit plans for Underwritten, Cost Plus and Large Cost-Plus groups.
  • Configured systems to process prescription drug claims according to Plan Benefits.
  • Implemented Pharmacy benefits for Health Care Reform Preventive and Contraceptive mandates.
  • Analyzed, interpreted and configured pharmacy benefits based upon group enrollment agreements and business requirements.
  • Updated existing benefits with the 2014 Health Care Reform Preventive and Contraceptive mandates.
  • Created new riders and update existing pharmacy benefit configurations with Prime Therapeutic Benefit Edit Tool (BET).
  • Configured New Pharmacy benefit packages in compliance with the Affordable Care Act prescription drug preventative care requirements and Essential Health Benefit Mandates.
  • Configured systems to process health and prescription claims to ensure accuracy of claims processing, benefit plan implementation and compliance with healthcare reform.
  • Configured benefits to insure accurate claims processing of member deductible, cost sharing and maximum out-of-pocket amounts.
  • Partnered with key stakeholders to identify and resolve any critical issues found as well as query the corporate systems to analyze data of current processes for improvement.
  • Answered “Client clarifies” and “Client notifications” and verified new Pharmacy benefits test results.
  • Tested plan benefits and rider updates to determine the accuracy of prescription drug codes, quality results and verification for release.
  • Transition tested claim lifecycle test execution, claim lifecycle test planning to validate accurate enrollment flow, nomenclature basics on ID cards, drug cost validation and claims processing.
  • Reported test results back to Prime Therapeutics and Pharmacy Benefit Manager (PBM).

Confidential

Business System Analyst

Responsibilities:

  • Implemented plan to plan reciprocal and standard pricing agreements for Confidential National accounts via the Confidential Inter-Plan Teleprocessing System (ITS) Facets 3.3.2.
  • Configured, revised, created updates, rejects and cancellations of Plan Profile Financial Agreements.
  • Audited, coded and performed Quality Assurance on new and existing Confidential Plan Profiles for accuracy.
  • Configured changes to Host/ Local Plan Codes and Group Prefixes for all Plan Migrations.
  • Cancelled Host/ Local 3 Letter prefixes and plan codes for a Confidential Cross and Confidential Shield Plan shutdown.
  • Configured and submitted Standard financial agreements to the Confidential Cross and Confidential Shield Association.
  • Monitored and maintained Home/Control and Host/Local Plan daily report.
  • Updated SharePoint Matrix detailing the completion of Home/Control and Host/Local Plan Profiles.
  • Emailed the National Accounts Marketing Department Analyst and Claims Department Manager when the Plan Profile financial agreements were completely configured in mainframe.
  • Updated the Claims Division Support and Analysis (CDSA) shared drive Matrix with all Plan Profile Financial agreement completions, migrations, prefix and plan shutdowns.
  • Filed all completed Plan Profile financial agreements for future reference and Auditing availability.
  • Attended weekly (CDSA) Claims Division Support and Analysis Staff Meetings and Monthly Department Joint Staff Meetings to discuss the progress of All Projects including the Healthcare Reform Act initiatives.

Claims Processing Analyst

Confidential

Responsibilities:

  • Processed Ancillary claims clinical laboratory, durable medical equipment and specialty pharmacy.
  • Participated as a Project team member in (CDSA) Claims Division Support and Analysis Department.
  • Resolved claims processing issues via the Confidential Inter-Plan Teleprocessing System (ITS) and the BCBS Association guidelines.
  • Pulled claims to test the quality of the Plan Profile prefixes for the Blue2 software release.
  • Reduced Ancillary Claim suspense by 75 % as associate’s quarterly Performance Improvement Plan (PIP).
  • Reduced Confidential ITS claim volume on Ancillary Provider Filing Post Implementation claims.
  • Increased adjudication and updated stop tables on clinical laboratory, durable medical equipment and specialty pharmacy claims.

Confidential

Customer Care Representative

Responsibilities:

  • Responded to customer questions via telephone regarding insurance benefits, provider contracts, outstanding inquiries, membership eligibility and claims status.
  • Analyzed each caller’s problems and provided the appropriate information and solutions.
  • Performed research and analysis on behalf of members, providers, group administrators, and brokers.
  • Provided research and status on health, dental, vision and pharmacy claims.
  • Received and placed follow-up telephone calls to answer customer questions that required research.
  • Developed and maintained positive customer relations with internal associates to ensure customer requests were handled appropriately and within a timely manner.
  • Documented the outcome and method of resolution of inquiries for future reference, tracking and analysis.

Confidential

Medicare Analyst Customer Service

Responsibilities:

  • Educated providers on the Centers for Medicare & Medicaid Services guidelines for claims, Medicare Part B benefits and all Medicare Part B services.
  • Provided providers with benefits for Medicare Part B Beneficiaries.
  • Assisted providers with the reason why their payments for Original Medicare claims were denied.
  • Instructed providers how to file for reimbursement and the eligible for their Medicare incentive bonus.
  • Advised providers in detail the reason for their Medicare Refunds Requests.
  • Advised providers how to dispute and submit Medicare appeals regarding refund requests.
  • Instructed providers how to accurately complete the Medicare Provider Enrollment application on the Confidential Medicare website and the CMS PECOS System.
  • Explained to providers the steps to correct problems with Edi electronic claim filing and denials.

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