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Medicare Regulatory Analyst Resume

SUMMARY

  • Experienced IT professional, data analyst, clinical assistant and health insurance advisor.
  • Awarded Master of Business Administration (MBA) and Doctor of Medicine (MD) degrees.
  • Ability to achieve strategic, financial, marketing, and operational management and business objectives.
  • Experience with large and complex financial and healthcare applications and interfaces.
  • Results - oriented and motivated professional with solid analytical, leadership, and communication skills.
  • Ability to guide a team, work in a team or work autonomously in a self-paced and self-motivated environment.

TECHNICAL SKILLS

  • Microsoft SQL Server Management Studio
  • Python
  • ‘R’
  • SQL Server Integration Services (SSIS) Project Solution (Visual Studio)
  • Clarabridge (Sentiment Analysis)
  • ASANA
  • MS Office
  • MS Words
  • COBOL II; SAS; CICS; VSAM; CICS Playback
  • MS-Project; Visual Basic
  • MS Excel
  • MS Access
  • Tableau
  • PowerBI (Dashboards
  • Query
  • Graphs
  • Data Modeling
  • Data Transformation
  • Reports
  • Maps
  • Pivot Tables
  • VLOOKUPS
  • HLOOKUPS
  • COUNTIFS
  • SUM
  • IF/AND
  • FILTERS)

PROFESSIONAL EXPERIENCE

Confidential

Medicare Regulatory Analyst

Responsibilities:

  • Actively monitored Medicare key performance indicators such as call center telephone standards for providers and customer quality initiatives including CTM, grievances, escalated inquiries and plan 5-Star rating to increase customer satisfaction and improve health care plan rating.
  • Analyzed work processes and developed software to track and report health care plan enrollments and trends including new members, disenrollments, net changes and termination reason. Reports and databases were used to facilitate complaint tracking, root cause analysis and management support.
  • Conducted business intelligence using data visualization and transformation techniques and tools to integrate data from different sources including SharePoint, SQL databases, spreadsheets and web sites into comprehensive dashboards and reports.
  • Developed tools and attended meetings to monitor results against established standards and conducted root cause analysis.
  • Provided executive and management summaries of trends for improvement areas as well as early detection of problem areas.
  • Completed forecasting models of customer calls utilizing different methodologies such as moving averages and exponentiation smoothing.
  • Produced ad hocs reports as required by internal and external customers.
  • Maintained current with Medicare federal and state health insurance laws and regulations changes which impact the field of work.
  • Participated in audits or review audit results to ensure compliance with standards and goals.
  • Maintained positive relationships with team members and management at all levels.
  • Demonstrated ability to analyze and solve problems, perform root cause analysis, and recommend improvement and coaching.
  • Utilized MS Project and Asana to track and monitor project completion.

Confidential

Clinical Coordinator

Responsibilities:

  • Under supervision of licensed physician, conducted activities including using eClinicalWorks health record management software to support efficient and effective medical encounter at patient’s home.
  • Prior to encounter, reviewed past patient notes, laboratories, diagnostic imaging and telephone encounters to identify and report patient needs including status of specialist referrals, laboratory, and diagnostic imaging results and durable medical equipment requested such as wheelchairs and diapers in a timely manner.
  • During the encounter, prepared patient for physical examination, assisted in taking patient history, and vital signs including blood pressure and O2 saturation. Conducted medicine reconciliation to ensure accuracy between medications at patient’s home and at pharmacy and/or discharge orders from hospitals and/or nursing homes.
  • After the visit, responsible for at least 50% of work load including completion of patient’s note with chief complaint, laboratories, diagnostic imaging, reconciled medications, refilled medications and ISTOP for controlled substances. Updated ICD-10 codes as necessary to reflect assessments for counseling, medical conditions and visit codes such as initial, follow-up, and transfer of care codes depending on severity of visit. Completed formularies such as MQ11 and DOH to determine patient needs for home health assistance, equipment, house modifications and other patient’s requirements.
  • Conducted patient chart and chronic care management record reviews.
  • Knowledgeable of eClinicalWorks and MEDGEN Electronic Health Records (EHR).

Confidential, Richardson, TX

Licensed Health Care Benefits Advisor

Responsibilities:

  • Demonstrated consultative skills to assess the client's needs and to determine eligibility for health insurance plan across multiple insurance carriers.
  • Effectively communicated costs and benefits of Medicare insurance plans.
  • Acted ethically and in compliance as defined by the company and governmental regulations such as privacy and HIPAA.
  • Worked effectively as a team member across departments to ensure an efficient processing of health insurance plan and to maintain productive work environment.
  • Excellent customer service skills that increased customer satisfaction and sales.
  • Demonstrated technical understanding of insurance products and/or insurance business/systems such as proficient use of sales management software applications.

Confidential, Dallas, TX

Software Quality Manager/Consultant

Responsibilities:

  • Analyzed financial applications especially tax applications for small businesses.
  • As Software Quality Manager, ensured the quality of financial software by ensuring it was prepared according to software requirements.
  • Managed and implemented change management through software builds and version control.
  • Developed and changed standardized and customized reports from databases and files.
  • Provided functional and non-functional test creation and execution to validate software during the full software lifecycle including unit, integration, system, performance and scalability tests. Assisted software team by developing and evaluating Software Development Plan, Software Quality Assurance Plan, Software Testing Plan and Software Configuration Management Plan.
  • Developed and implemented software quality metrics "dashboard" which was used to forecast quality trends and to develop strategies for process improvement. Conducted assessments and reviews of software development activities to ensure compliance with Software Quality Assurance Plan and other plans as applicable.

Confidential, Austin, TX

Software Quality Consultant

Responsibilities:

  • Analyzed financial applications especially insurance applications.
  • Implemented best practices and software quality strategy and vision.
  • Guided coached, and mentored team members and project leaders in quality concepts and techniques such as improving or tailoring project deliverables to meet standards.
  • Managed complex project plans including estimating the work to be performed, establishing the necessary commitments by integrating knowledge of multiple business areas, and defining the plan to perform the work. Ensure that allocated requirements were used as the basis for estimating, planning, performing, and tracking process improvement.
  • Evaluated and documented corporate software testing procedures including unit, integration, system, and regression testing.

Confidential, Austin, TX

Test Manager/Section Leader

Responsibilities:

  • Analyzed financial business practices to implement and test financial systems and interfaces including general ledger, purchasing, budgeting, payroll, and human resources.
  • Provided software quality strategy and vision. Implemented best practices, QA and test methodologies and process improvement activities.
  • Served in multiple teams that evaluated and coordinated subcontractor activities such selection, establishing commitments, and tracking performance.
  • Team leader or member of teams responsible for conducting post-implementation reviews and audits of software activities.
  • Conducted root cause analysis with software developers to evaluate defects and to develop resolutions to prevent problems from recurring. Served as member of team that conducts Software Capability Evaluations (SCEs) that is led by a SEI-authorized Lead Evaluator. Developed, maintained and updated process asset library.
  • Developed and maintained client/server GUI/Windows applications utilizing Visual Basic, Microsoft SQL Server, OBDC and Crystal Reports.
  • Led and coordinated development of software applications and utilities written in CICS, IDMS, DB2, SAS and COBOL to support the testing and auditing of financial applications.
  • Prepared and executed test plans to ensure reliability of large and complex financial information systems.

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