Cms Auditor Resume
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SUMMARY
- Dedicated Healthcare professional with more than 22 years of combined experience, as a QNXT and Facet Configuration Analyst, Tester, UAT Business System Analyst II, Quality Analyst, Claims Operations Manager, Field Operations Manager, Senior Team Lead, Senior Auditor, Recovery/Adjustment Analyst, Grievance and Appeals Specialist and Senior Claims Analyst.
- Experienced in Implementation, Building and Testing products and HIPPA Privacy.
- A vast amount of experience in all lines of health insurance including Medicare, Medicare Advantage, Medicaid, Product Builder, Medicare Compliance and Provider Contracts background, HMO, IPO, PPO EPO, TPA’s and Customer Service.
- I effectively manage large projects, multiple high - priority projects and take pride in providing exemplary customer service to the client and staff.
- Good communication, presentation, organizational and planning skills.
- Good interpersonal skills to work as a team member.
- Ability to communicate with customers, physicians, facilities and insurance carriers.
- Exceptional ability to work in a pressured environment, very versatile and easy to adapt.
- Extensive knowledge of Excel, Word, Power Point, Lotus Notes and other office software.
- PECOS ( Provider Enrollment Chain and Ownership System) Training
PROFESSIONAL EXPERIENCE
CMS Auditor
Confidential
Responsibilities:
- Analyze federal and state regulations/ policies for Medicaid and CHIP reimbursements.
- Conduct audits to determine if reimbursements to medical providers were in compliance with regulations and policies.
- Verify member, eligibility, date of service, coverage period.
- Verify providers credentials( license, enrollment, billing address etc.,)
- Determine criteria for defining error. (entire claim, targeted claims, financial, coding, duplicates, authorizations, etc.)
- Conduct second level reviews of audits made by fellow auditors.
- Maintain confidentiality of patient information in accordance with HIPPA regulations.
- Conduct queries and communicate data findings in written and oral reports as well as presentations.
QNXT Configuration Analyst /Tester
Confidential
Responsibilities:
- Load Provider information into the system from start to finish.
- Complete provider add/change forms from Networks.
- Set up specialties, network affiliations, and other provider configuration items to help with different claims payment issues.
- Set up many different contracts with different payment methodologies such as: Capitated, FFS, Hospital, Medicaid, ASC, Ancillary and special custom contracts as well.
- Knowledge with contract module to help coordinate contract set up with benefit set up to produce the desire claims payment results.
- Knowledge of System Configuration modules and know where to add and update configuration items like bill types, modifiers, attributes, ICD10 codes and other items to make QNXT function as desired.
- Implemented new Plan Benefit setup and hierarchy based on the specific business requirement needs of the health plan.
- Updates and modification of benefit plan setup based on plan design changes of existing plans.
- Develop and architect all hierarchy levels in QNXT system for relational efficiencies as it pertains to efficient claims auto adjudication.
- Review and verify by testing claims to ensure plan setup is accurately configured in QNXT system.
- Support quality review and testing of QNXT System setup prior to production implementation.
- Resolve escalated and complex claims processing, change requests, issues or questions regarding of any benefits and configuration.
- Responsible for workflow assignments and taking the initiative to resolve problems and meet deadlines.
- Support quality reviews and testing of QNXT system prior to production implementation.
Facets Configuration Analyst/UAT Business System Analyst
Confidential
Responsibilities:
- Load provider demographics, contracts and plan benefits within the Facets 5.01 environment for Medicare, Medicaid and Commercial lines of business.
- Assisted with Facets 5.01 new implementation, upgrades, assessments, and system integration.
- Loaded and validated Benefit Summary based on Medical Plan and Benefit Plan Build.
- Worked with Accumulators, COB, deductibles, overrides of claim line detail and used them for testing various scenarios
- Received Service Reports (SR’s), via email and Service Request Data Base, analyze problems, ran SQL queries, configured new sepys, service rules and service ID’s as necessary.
- Address issues with FACETS 5.01 Pricing and Benefits
- Develop and execute user acceptance testing (UAT) test plans to ensure that the functionality developed delivers the results outlined in the business requirements.
- Work Issues through a Service Request Inventory database
- Documenting configuring testing and implementing solutions
- Using the FACETS CMU tool to move data in between environments
- Identifying and Creating DEFECTS in RQM (Rational Quality Manager) gathering defect metrics and reporting test results
- Creating and Executing test scripts in ClearQuest Develop and execute user acceptance testing (UAT) test plans to ensure that the functionality developed delivers the results outlined in the business requirements.
- Work Issues through a Service Request Inventory database
- Performed product audits and peer reviews.
- Implementing: pricing, capitation, membership and enrollment, provider setup, provider contracts, benefit plan build, benefit grids for UAT Testing and configuration
- Used Networx Pricer to build qualifier groups (Revenue Codes) create contracts (DRG, Per Diem)
- Document business requirements, focusing on supplemental tables, TPCT, RCCT,SPCT, SRCT,SEPY, SESE,DEDE,LTLT, BSBS,PDBL’s
- Participate in the review and approval process of various claim audit test activities.