SUMMARY

• 26+ years experience in insurance industries (Worker’s Compensation, Healthcare and Liability lines of business).
• Knowledge of all healthcare standard code (CPT4, ICD - 9, HCPCS, and Revenue Codes).
• Strong bill review and technical assistance background. Strong communication skills, both orally and in writing.
• Meticulous attention to detail researching and analyzing issues while managing competing priorities.
• Proven ability to deal TEMPeffectively with a variety of personalities to establish and maintain working relationships at all levels within and outside teh organization.
• Able to work independently and in team environment. Skilled in teh following areas:
• Worker’s Compensation Bill Processing
• Auditing/Quality Assurance
• MS Excel, MS Access and MS Word
• Research and Analytical Ana lysis
• Written Communication Training

PROFESSIONAL EXPERIENCE

Senior Data Analyst

Confidential, Dublin, Ohio

Responsibilities:

• These duties were in addition to maintaining teh duties of Data Specialist (See Below)
• Mentoring of multiple co-workers
• SOC1 Reporting and Monitoring
• StrataWare and OSS Security Reviews
• Create documentation of departmental processes
• Increased project involvement at both corporate and local business unit level
• Managed all new business testing
• Handled special auditing for client DDC
• Primary point of contact for security management
• Provided SBR Technical assistance through ticketing system and emails

Medical Bill Processor

Confidential, Dublin, Ohio

Responsibilities:

• Review hospital and professional medical bills from provider, including complex hospital, surgical, high level evaluation and management codes, and/or technical bills.
• Process bills in accordance with multi state schedules, rules, regulations and guidelines while maintain or exceeding 97% combined accuracy rate.
• Run reports, transfer and process low complexity reconsiderations.
• Manage Service Level Agreement Client’s volume to ensure agreements are met. Increased performance an average of 2.43% since assuming responsibility in October 2010.
• Process Pend/Returns on a back-up basis.
• Used judgment concerning questionable healthcare claims needing review, determined covered and non-covered charges based on specific plan language, obtaining additional information when needed, and issued payment when appropriate.
• Maintained required accuracy and production standards of 98%.
• Responded to verbal and written inquires from group contacts, brokers, providers, insureds and DOI regarding benefits, enrollment and claims situations.

Special Projects Group Lead

Confidential, Columbus, Ohio

• Responsible for developing and managing workflow for new business niche of back-shopping healthcare claims (being an “invisible TPA”).
• Coordinated all aspects of migration of a block of business consisting of 21 employer groups onto a new system platform.
• Created team consisting of members of staff, client, and client business partners to determine specifications and create inbound/outbound electronic feeds.
• Monitored workflows and progress of all migration team members to ensure target completion dates met, making adjustments to workload and timetables as needed.
• Coordinated validation of data conversions.
• Developed, documented and supervised quality assurance measures and testing including benefit configuration, system enhancements, report validations and error reports.
• Initiated close communication with client to create accurate benefit coding document based on their plan documents.
• Wrote training materials and trained client on system use.

Business Analyst II

Confidential, Columbus, Ohio

Responsibilities:

• Collaborated with business process owners to identify opportunities, define business requirements, and design and implement solutions to maximize efficiency and productivity.
• Coded system platform for claim processing and auto-adjudication.
• Designed and coordinated creation of end of month reporting according to client’s specifications.
• Monitored claims accuracy percentages with teh goal of identifying improvement potential.
• Proactively identified configuration or coding inaccuracies by monitoring accuracy of output including bills, invoices, EOB’s, checks, reports and other extracts.
• Created and executed adhoc queries and reports.
• Created test scenario’s and tested system enhancements and system coding.
• Facilitated large volume data conversions, data cleansing, production report generation, and upheld scheduled data delivery standards

Senior Representative Technical Unit

Confidential, Columbus, Ohio

Responsibilities:

• These duties were in addition to maintaining teh duties of High Dollar Specialist (See Below)
• Adjusted previously processed claims to correct errors and alter check amounts, posting refund payments where applicable.
• Responsible for pre-existing exclusion investigations, which included obtaining medical records, reviewing this documentation to determine non-covered conditions, tan flagging teh system for future claims processing.
• Researched and responded to appeals from group contacts, brokers, providers, insureds and DOI.
• Performed initial investigations of possible fraudulent claims.
• Wrote training materials and trained peers and clients on system use and claims processing.

High Dollar Specialist

Confidential, Columbus, Ohio

Responsibilities:

• Processed all claims with a total charge of $20,000 or greater, applying more stringent auditing practices; including obtaining and reviewing operative reports, hospital summaries and consultant reviews.
• Coordinated all efforts of contracted vendors to obtain eligible non-PPO discounts.
• Audited vendor invoices to determine non-PPO discounts used and/or accepted by teh provider of service, adjusting claims where necessary, and issued payment to vendor for discounts used.
• Was primary claim and customer service point of contact for insureds, providers of service and employer group contacts; handling all phone calls, written correspondence, claim payment and adjustments.
• Maintained high level of accuracy while meeting turn-around service commitments.
• Involved in on-site visits to employer groups during open enrollment and renewal periods, answering general questions regarding benefits, as well as having one-on-one meetings with insureds to go over individualized claim questions.