PROFESSIONAL EXPERIENCE:

Confidential - Washington D.C.

Data Analyst

Responsibilities:

• Collaborated with multidisciplinary staff and senior management to design, implement, and evaluate outcomes for operational improvement initiatives: Reduction on pay for performance initiative regarding Emergency Room visits and recurring Inpatient admissions Provided data to the Outreach department in order to target high volume offenders in the ER initiative Identified for the Clinical Director members that are as high risk in case management and provided specific recommendations for program direction Assisted with monthly Encounter Reconciliation Accountable for problem identification and resolution within data warehouse with respect to accessing, accumulating, and processing information
• Maintains knowledge of current accreditation, regulatory and healthcare quality, clinical practices, and quality measurement requirements and standards for Medicaid members in the District of Columbia
• Develop ad-hoc analytical reports from data warehouse using SQL
• United Healthcare Group - Telecommute

Confidential

Data Analyst

Responsibilities:

• Extract data from SAS, aggregate and perform Quality Assurance on applicable data from multiple sources and tables for purposes of root cause analysis, action development, and validation and measurement of HEDIS administrative data initiatives Research, retrieve, design, troubleshoot, and deliver organized analytics regarding healthcare data pertaining to HEDIS mesure performance and improvement opportunities Developed claims Quality Assurance audit process Developed Audit tool dashboard using Tableau Documented project requirements and developed test cases for claims audit process Work with claims team to identify areas of opportunity and to drive efficiencies in Hedis measure performance Provide ongoing communication on project status, results and conclusions from analysis Work with IT to build ongoing reporting needs into the production environment

Confidential

Data Analyst

Responsibilities:

• Perform and review daily/monthly routine system balancing and provide approval for subject areas Documented project requirements and developed test cases Map and consolidate data elements on various systems
• Extracting data using SQL to generate reports and supporting detailed data sets to address key business needs and support product operations Collaborated with IT, and key business teams on the development and implementation of strategic business solutions through research and data analysis Provided data for Call Center and Clinical Outreach departments in marketing efforts including: education, orientations, medical updates etc Served as the SME for system logic, ETL production loads, and Quality Assurance process Assists in design, implementation, monitoring, and evaluation of population health interventions Developed an interventions management dashboard using Tableau
• Provide analytical support for quality reporting and data collection activities using Tableau and Excel Monitored weekly and monthly intervention reports for clinical staff and made recommendation regarding intervention outreach to members and providers Performed monthly financial validation, conducting and documenting financial / business variance analysis and research Fulfill those responsibilities and/or duties that contribute to achieving operational and financial success
• Designed, developed, and produced ad-hoc reports using Microsoft SQL Server Management Studio Worked with management to develop and apply methodologies to classify, quantify, and/or forecast business metrics Analyzes and evaluates the effectiveness of quality measurement and activities to identify and prioritize process improvements and gaps in care Was accountable to the Sr. Clinical Director related to all reporting measures, analysis and metrics that was reported to the client Developed marketing campaigns from population based quality surveys to inform quality improvement interventions for the DM programs Determine the methodologies and procedures for carrying out effective data analysis. Provided training as needed

Confidential

Data Analyst

Responsibilities:

• Maintain contract repository, including key terms, rates, correspondence Produced periodic reports of insurance enrollment in and around each site/region and changes from previous months Maintain a listing of networks of each contracted payer, targeted payer and contractual rates Developed a payer volume report (measured by dollars and services) by site and in aggregate Produced operating metrics vs plan: marketing, sales, conversion, and retention Worked closely with the IT department and clinical staff on the new software to develop reports
• Running SQL queries, interpreting and analyzing data for end users Develop and analyze business performance reports: detail on performance deviations and anomalies Perform and review daily/monthly routine system balancing and provide approval for subject areas such as Claims, Enrollment, Revenue, Employer Groups, Products and Providers so data can be released to internal and external users. Maintain technical and functional systems documentation such as mapping documents, Standard Operating Procedures, extract specifications and transformation specifications to ensure information is accurate and up to date. Collaborated with regional VP’s regarding data findings and provided recommendations as needed Report analysis consists of: Practice Performance Analysis, Market Trend Analysis and Cost Analysis, Fee Schedule analysis. Monthly reports determine Denial Information, Production reporting, A/R reporting, and Occurrence Determinations Identify systemic issues, gaps and inconsistencies. Work closely with IT dept. in developing, & modification to extract tool Provide recommendation on the implementation of new/revised operational and/or reporting processes Respond to ad-hoc report requests internally & externally
• Developed marketing campaign to recruit physicians, medical groups, IPA’s and hospitals for the network. Negotiate contracts with medical providers, including medical groups, IPA’S, hospitals, and ancillaries Develop in service training materials and performs in-service provider meetings and orientations concerning company benefit plans, credentialing, Quality Assurance programs, administrative procedures, and other policies. Develop, and analyze competitive fee schedule for network enhancement Project lead on new implementations within the department: including new system facilitator, CAQH, credentialing and sales. Ensure compliance and HIPAA regulations within the provider network for N.Y. and N.J. Supervised provider field reps, ancillary contractor and administrative assistant for the NY office. Responsible for providing weekly production reports to Provider Relations Director and conducting weekly production meetings with staff Developed Provider/Credentialing database in Access for storing of data. Developed reports from this database based on Claims, Credentialing, Production, and Network Development Developed reports for Sales division which include Cost Analysis and developed potential business interests

Confidential

Facility Contract Negotiator/Data Analyst

Responsibilities:

• Negotiate contracts with mental health facilities and ancillary groups Interact with providers (individual and institutional) and their office staff, to provide program information and to accomplish problem resolution.
• Responsible for implementation of new line of business into current MHN network Responsible for determining holes in the network, by utilizing Geo-Access reports and claims data Responsible for providing reports to VP of Network Development which include: in & out of network providers, status of credentialed provider, and claims data Used Symphony program for monthly reports to be distributed for the entire Eastern region (23 states) which include: Status reports, Claims data, A/R reports, Credentialing, Geo-Access
• Developed marketing plan in the recruitment, application, credentialing, and contract issuance process. Conduct and assist with provider education sessions. Delegate work to support staff as appropriate. Provide feedback to Provider Relations Manager as to the productivity of the support staff relative to the credentialing process. Training providers on contractual issues as well as network issues. Responsible for gathering, processing credentialing information for potential providers.

Confidential

Provider Relations Assoc. /Data Analyst

Responsibilities:

• Conduct provider recruitment, education, claims resolution and communication of HIP policies and procedures to the provider community. Developing and running database reports using SQL for data analysis. Assisting in the recommendation of contracting strategies to maximize cost containment through report analysis. Contributed as a liaison between network providers and business/sales team Credentialing physician application for determinations Answering provider inquiry calls regarding claims, applications, and miscellaneous questions
• Assisted in representing the Fidelis Plan to individual providers and members of their staff in marketing, and recruitment. Conduct site reviews for new and prospective providers. Negotiate contractual issues with existing hospital groups and IPA’s. Visit providers periodically for continuing education in Plan policies and procedures, managed care practice, and Utilization management guidelines.
• Recruiting physicians via telephone to participate in managed care network. Tracking and inputting physician’s applications. Credentialing physician applications for determinations. Answering provider and client inquiry calls regarding claims, applications, and miscellaneous questions.

Confidential

Data Coordinator/Underwriting

Responsibilities:

• Insure accuracy of data in departmental databases by continually updating and verifying data. Running, release, and analysis of production reports using OLAP. Analyzing utilization data for HMO specific products. Coordinating the collection of data to support department accounts. Maintaining back-up documentation to support program factor/database changes.
• Examines, researches, and defines the most appropriate method of resolution and performs thenecessary claims processing.
• Examines, interprets, and responds to written correspondence and telephone inquiries received from customers and providers.
• Ensure customer information for proper processing of claim information Responsible for telephone unit production including preparation of weekly reports, assisted in weekly meeting with management regarding productivity and training