To obtain a challenging and rewarding position with an organization that will effectively utilize my experience, training, and achievements.
- Offering a diverse background of healthcare experience and training in customer service, claims adjustment, internal claims auditing, PPO, HMO, MCO, data processing, CPT and ICD-9 codes, provisions and exclusions, payments and refunds, recovery auditing, federal and state insurance laws, personnel training and supervision, and implementing procedural policies.
- Strengths include excellent organizational, time management, leadership, interpersonal, and problem solving skills. Highly motivated, self-starter, with team player abilities.
- Consistently receive excellent performance evaluations in all positions held.
- Able to easily establish and maintain effective business & customer relationships.
- Computer proficient (WindowsXP, MS Word, MS Excel, MS Access, MS Project, Test Director, Data Junction, Healthcare Claims Software, Healthcare Accounts Receivable Software, IBM Rational Suite, Silk Central Suite, Oracle SQL, Microsoft SQL Server, Citrix, SharePoint).
Confidential,May 2006 - August 2008
Systems Consulting Senior Analyst
- Familiarity with standard concepts, practices, and procedures within the healthcare field and MMIS.
- Interprets business needs and translates these into system requirements by interaction with Business Analysts and Developers in a formal SDLC environment.
- Create test deliverables (i.e. cases, scripts, and results) based on a use case approach along with sequence diagrams.
- Develop and review manual test case scenarios for functional, system, and product validation
- Participates in testing, across multiple project organizations to meet multiple requirements (i.e. functional, stress, endurance, etc.).
- Document testing results including incorporation of appropriate artifacts.
- Document defects and track these through successful resolution.
Confidential,April 2005 - May 2006
Senior Client Data Analyst
- Implemented clients into the companys disease management programs.
- Understand the business flows and overall healthcare process and how health insurances work.
- Interface with the companys clients, Account Management, Data Developers and Data Analysts in performing analysis and creating data processing requirements for clients.
- Execute work with companys partners regarding file format and content requirements.
- Create SQL queries for data set analysis.
- Analyze and map client data to companys standards and assist in defining requirements.
- Review client data for required field content.
- Acknowledge general database experience and data warehousing.
Confidential,May 2001 - April 2005
- Perform review of health claims payment accuracy for healthcare payers.
- Conduct analysis of claims based on contractual terms and documentation.
- Interface with medical providers to recover overpayment made on claims via telephone or written request.
- Consult with clients to implement the recovery process.
- Train staff on the auditing and recovery practices, policies, and procedures.
Confidential, LLCApril 1999 - March 2001
- Performed insurance follow-up to healthcare payers, Medicare, Medicaid, and Tricare for medical providers.
- Implemented billing procedures to healthcare payers and government programs.
- Interfaced with patients and insurance personnel in reference to financial services and accounts receivable.
- Reviewed and tracked accounts for light collections processing.
Medical Claims Consultant
- Adjudicated and reviewed medical and dental claims in a managed care environment.
- Processed telephone inquiries from policyholders, service providers, and other medical personnel regarding claims status, plan coverage, provisions, and exclusions.
Confidential,April 1994 - January 1999
- Provided training to company personnel in processes and practices for using payment, benefits and claims systems software.
- Performed remedial training when required.
- Received excellent training evaluations from students based on written surveys.
- Perform transaction analysis of doctors, hospitals and medical centers financial computer data records to process claims adjustments, recover overpayments made to providers, and issued payments not received.
- Interfaced professionally with customer service representatives, claims, auditing, accounting and training departments.
Senior Healthcare Claims Examiner
- Performed claims adjudication on healthcare medical, dental, and vision accounts.
- Implemented various insurance plans, including PPO, HMO, MCO, and coordinated benefits with healthcare payers, TPAs, Tricare, Medicare, and Medicaid.
- Processed telephone inquiries from policyholders, service providers, and other medical personnel regarding claims status, plan coverage, provisions and exclusions.
Bachelor of Science Biology