SUMMARY:

Astute, results - oriented, Bachelor-degreed professional seeks suitable, upwardly mobile position that welcomes a seasoned professional with an exceptional ability to work under pressure. Professional career reflects over 15 years of healthcare experience with proficiency in claims, membership, enrollment, internal auditing, over-payment recovery and data analysis. An out-of-the-box thinker with a flair for identifying and adapting emerging trends to analyze and streamline processes. Ability to quickly grasp procedures and methods, easily adapts to new situations, communicates in a clear, concise, and understandable manner and coordinates with all levels of personnel.

EXPERTISE AREA:

• Commensurate professional in analyzing, examining, investigating, adjudicating and authorizing claims for all aspects of insurance entitlements
• Outstanding oral and written communication skills
• Experienced with QNXT 5.3, FACETS, Xcelys, MHC & Diamond claims processing systems
• Thrives in time-fused and deadline-driven environments
• Conducted quality audits for claims associates
• Extensive knowledge of Encoder Pro, Med-Assets, MACESS, Medicaid, Medi-Cal, Medicare & Commercial health insurance policies and programs
• Working knowledge of conducting data analysis for reporting via Microsoft Access/Visual Basic databases
• Proficient in the complete Microsoft suite with knowledge of developing/building web pages
• Ensured assigned projects meet or exceed quality standards

PROFESSIONAL EXPERIENCE:

Confidential

Business Systems Analyst

Responsibilities:

• Analyzes and tests Provider Contracts, Benefits and Fee Schedules in Molina’s core operating system to ensure accurate and timely claims payment.
• Ensures accurate interpretation of benefit requirements and definitions to deliver correct system configuration, reimbursement methodology and Benefit Program data elements that are required to configure the system.
• Applies critical thinking and problem solving with respect to System Configuration.
• Understand the downstream impact of benefit data, provider contract requirements, and claims processing
• Understands claims processing system logic and rules, and their impact to system configuration
• Performs system cause analysis, based on inaccuracy or erroneous Claim payment with respect to the Benefit, Contract, and Fee Schedule
• Configures Professional and Institutional Providers or Complex Benefits.
• Manages special, high urgent and critical assignments/projects to meet rigorous timelines with expected outcome.
• Conducts preliminary evaluation of contractual agreement prior to execution to determine system configurability.
• Conducts systems requirement assessment in support of regulatory changes (e.g. ICD-10, ASC, DRG etc).
• Analyzes business requirements to determine the best approach for configuration design, testing and implementation.
• Analyzes benefit evidence of coverage to determine best approach for loading benefit plans offered including co-pays, out-of-pocket maximums and state/regulatory benefits coverage.
• Develops, documents and executes test plans for configuration testing and validates accuracy of data loaded.
• Acts as the liaison between business configuration and business owners to ensure that all application and technical-oriented issues relating to the configuration requests/projects are appropriately addressed.
• Tests new version releases relative to system configuration and documents results.
• Analyzes and make recommendations to management regarding system enhancements and communicates system problems and impact on operations.
• Acts as the subject matter expert regarding claims processing issues. Assists in establishing, and documenting policies and procedures in support of standardized and accurate configuration.
• Validates design, testing and implementation of Configuration.
• Conducts preliminary evaluation of contractual agreement prior to execution to determine system configurability and the outcome to improve auto-adjudication of processed claims.
• Conducts system requirement analysis and evaluation to meet regulatory changes and updates.
• Tests and audits Pre- and Post-production reports to ensure accurate and valid system

Confidential

Project Coordinator

• Worked directly with Project Manager(s) to determine daily priorities, tasks to be completed, plan and reach milestones during the project
• Compiled image packets to be used for upload to CMS
• Scanned hard copy records to electronic form for processing
• Worked with various department protocols to transfer data safely
• Reconciled data from various source documents into one final source document and create client facing reporting/tracking
• Create and QA add/delete files for processing

Confidential

Technial Analyst

• Provided claims expertise support by reviewing, researching and investigating claims data
• Analyzed claims data, identified trends, and provided reports as necessary
• Performed queries and extracts of member claims and provider data
• Assisted with timely HEDIS and monthly/quarterly utilization reporting

Confidential

Plan Specialist

• Performed high-level contract overview to ensure accuracy of contract terms and conditions. Analyzed, trended and escalated issues as needed to the appropriate stakeholders.
• Reviewed and researched payment account adjudication, billing results and disputed claim patterns for assigned payers
• Worked required reports (daily, weekly, monthly) to ensure claims processing integrity based on established guidelines provided by management
• Coordinated efforts with stakeholders to drive changes in auto adjudication, aging and cycle time
• Provided feedback to operations and other stakeholders regarding payer trend status resolution

Confidential

Quality Analyst/Project Coordinator

• Ensured the correct configuration and functioning of the Qnxt claims processing system by consulting/collaborating with claims, configuration, and IT departments to ensure that all issues identified by claims department contributing to inaccurate or inefficient processing are addressed
• Created work plans for provider resolution claims project
• Provided in-depth root cause analysis along with proposals and recommendations for next project phase
• Audited claims by reviewing all system data and payment methodologies to ensure compliance with all contractual obligations as agreed to by the group, subscriber and provider
• Attended work group meetings and assisted project manager with determination of project scope and requirements
• Effectively and accurately communicated relevant project information to work group, project team and other key stakeholders
• Performed technical and analytical work to support the functional and reporting requirements of the Business Process Improvement (BPI) unit
• Documented test results in work papers reviewed by the project manager or configuration lead analyst
• Keep the project manager/configuration lead analyst informed of audit findings and assist the team with the development of management action plans to mitigate weaknesses and take corrective action where appropriate

Confidential

Senior Claims Analyst

• Evaluate claim submissions for completeness, program eligibility status and medical appropriateness
• Initiates correspondence requesting information on incomplete forms in order to adequately process claims
• Enter primary care encounter information and fee-for-service claims received both in paper and electronic formats
• Identify, track and reconcile over payments made to providers ensuring that overpayment recovery is made and reported
• Research and identify potential overpayments made to providers through independent work
• Utilize provider contracts system to manually price claims according to contract terms
• Prepare and send correspondence to providers notifying them of claims overpayments
• Perform QA system, unit, acceptance, regression, load and functional/performance testing in QNXT using automated and manual testing

Confidential

Staffing Claims Analyst

• Examine claims to identify key elements and processing requirements based on diagnosis, provider, medical policy, contracts, policies and procedures
• Efficiently and accurately process product- or system-specific claims to ensure timely payments are generated
• Calculate deductibles and maximums, as well as research and resolve system pends
• Process high and low dollar volume claims in accordance with standard policies and procedures
• Assist Customer Service Reps by providing feedback, resolving issues and answering basic processing questions
• Perform QA system, unit, acceptance, regression, load and functional/performance testing on Facets

Confidential

Administrative Grant Assistant

• Ensure compliance with applicable federal and/or state laws, regulations, and/or policies and procedures
• Ensure all required aspects of the grant review are completed according to specifications and to contract requirements
• Meet and confer with management to resolve problems and coordinate services
• Research and use agency and community resources and services
• Update and maintain online grant monthly reporting /tracking system
• Complete assigned projects in a timely fashion amine claims to identify key elements and processing requirements based on diagnosis, provider, medical policy, contracts, policies and procedures

Confidential

Member/Claims Services Representative

• Provide first-call resolution for providers by investigating or reprocessing claims based on provider’s issues
• Answer and document all incoming calls for the Member Services Department
• Research and respond to inquiries of existing members, prospective members, group representatives, outside service providers and others regarding health plan benefit, claims, services and products
• Respond to complaints from members concerning Health Plan benefits, account status, provider and/or member claims status, payment history and medical services
• Performed other duties as directed