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Health Insurance Payment Analyst Resume

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SUMMARY

  • Instructional design and development cycle, to improve the instructional integrity of all training materials.
  • Utilized the LMS as the primary tool to capture and share information
  • Provided services and support to 200+ employees and 75+ additionally assigned personnel
  • Implemented and maintained compliance with all personnel policies, procedures and regulations with the responsibility of ensuring all contracts, reports and forms were completed properly and on time
  • Improvements to existing processes life cycles, exploring new technologies, and implementing best practices on an ongoing basis for complex automated end - user applications/end-user support
  • Strong knowledge of and experience utilizing needs assessment, training programs development/evaluation, adult-learning theory and applications.
  • Delivery of learning solutions include: quality assurance, instructor-led training, web-based training, blended learning, on-the-job training, job aids, model office, simulations, and performance support materials.

TECHNICAL SKILLS

  • Microsoft Windows (DOS, NT, 3.11-XP ), Windows Network Server/TCP/IP, Managed Healthcare Systems (MHS & MHS PLUS), DMARS, Adobe Macromedia, Visio, VMWare, Cache, Gelco, IDX, Banner, AS400, VistA, Learning Management Systems, Adobe Acrobat, Corel Office Suite, IBM Directory, SMERF, GUI, Group Wise, Encompass, Microsoft Office Applications-Word, Excel, Powerpoint & numerous other software packages.

PROFESSIONAL EXPERIENCE

Confidential

Health Insurance Payment Analyst

Responsibilities:

  • Conducts detailed and precise audits and second-level reviews of claims processing systems across the U.S., onsite at state agencies, and remotely to determine if monies paid by the states were made in accordance with federal and state policies for Medicaid and CHIP (Children Health Insurance Program).
  • Utilize various agencies systems to determine claims processing systems across the U.S., onsite at state agencies, and remotely to determine if monies paid by the states were made in accordance with federal and state policies for Medicaid and CHIP.
  • Analyzes federal and state regulations / policies for Medicaid and CHIP reimbursements.
  • Conducts audits and leads audit teams to determine if reimbursements to medical providers were in compliance with regulations and policies.
  • Knowledgeable of Current Procedural Terminology (CPT) codes, International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-9 and 10-CM) codes, and Healthcare Common Procedure Coding System (HCPCS) codes.

HealthChoice Community Liaison & Care Coordinator

Confidential

Responsibilities:

  • Educated enrollees, public and providers on Medicaid services on the functionality by responding to requests for assistance and ensuring their needs are met. Refer any inquires or concerns by callers as needed upon making accurate assessment of recipient/provider.
  • Utilized Rumba database to collect and log in information verifying eligibility benefits.
  • Provided recommendations to supervisors after review of complaint trends notating what processes or procedures could be amended to provide more efficient assistance to providers.
  • Triaged various 800 hotlines for the HealthChoice and Acute Care Administration in the Division of HealthChoice Customer Relations.
  • Utilized Medicaid Management Information System (MMIS) in conjunction with the Maryland Health Benefit Exchange to provide customer service and resolution of recipient and provider concerns for various Medicaid programs which include, but are not limited to, HealthChoice, Primary Adult Care (PAC), Medicaid Expansion Programs, Maryland Children's Health Program (MCHP), and Family Planning (FP) program Triage all medical complaints from recipients and providers in the Medicaid programs documenting complaint issues in the Provider Recipient Omnibus Management Information System (PROMIS) database. All complex complaints are referred to the Complaint Resolution Unit within the Division of Outreach and Care Coordination.
  • Demonstrated understanding and ability to apply Code of Maryland Regulations (COMAR) State policies to Medicaid programs.

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