SUMMARY:

• Healthcare Consultant with experience in the Managed Care Industry utilizing Project Management Methodology.
• Demonstrated success as a Benefit Configuration Analyst (Pharmacy), BlueCard ITS Plan Profile Configuration Analyst/ Business System Analyst, Claims Analyst, Medicare Analyst, Customer Service Analyst, Customer Benefit Administration Analyst, Tech Support Analyst and Healthcare Insurance Consultant Subject Matter Expert (SME).
• Experience working with a Conglomerate of Software Applications and Operating Systems.
• Bachelor’s Degree in Communication Studies with excellent verbal, written and listening communication skills.
• Demonstrated ability to learn tasks quickly, analyze data and understand relationships.
• Ability to effectively handle multiple projects simultaneously and give individual attention and details to each with priorities on excellent quality, task management, time management and completing projects within required deadlines.
• Experience working with several lines of business including but not limited to EPO, HMO, PPO, BlueCard ITS, Medical, Dental, Vision, Pharmacy, Medicaid, Commercial Health, Original Medicare, Medigap and Medicare Replacement Plans (Medicare Advantage - Medicare Part C).
• Excellent leadership and Project Team Building skills.
• Seeking a position that will utilize my experience, skills and knowledge as a viable resource who will contribute to your company’s profitability and success.

PROFESSIONAL EXPERIENCE:

Confidential

Medicare Analyst

• Educate providers on the Centers for Medicare & Medicaid Services Guidelines for claims, Medicare Part B benefits and all Medicare Part B services.
• Provide Callers with specific benefits requested for Medicare Part B Beneficiaries.
• Verify Beneficiaries Medicare Part B Eligibility and Entitlement details.
• Assist providers with the reason why their payments for Original Medicare claims were denied.
• Gives details regarding Medicare Secondary Payer (MSP), Coordination of Benefits (COB) and Medicare not eligible services due to Member’s Medicare Replacement Plan Enrollment.
• Instruct providers how to submit claim denial First level Redetermination Appeals and subsequent Second and Third level appeals if warranted.
• Advise providers in detail the reason for their Medicare Payment Offset and Refunds Requests.
• Answers provider’s questions regarding their Remittance check numbers and payments discrepancies.
• Advised providers how to dispute and submit Medicare appeals regarding refund requests.

Confidential,New Jersey,Newark

Medicare Analyst

• Verified member dual eligibility in New Jersey Medicaid and Medicare Parts A and B.
• Ensured that Medicare Advantage membership enrollment was in sync by reconciling CMS enrollment records and Horizon enrollment records.
• Reviewed Daily Transaction Reply Reports (DTRR) and the Monthly Membership Reports (MMR) while abiding by Federal Centers for Medicare and Medicaid Services guidance (CMS).
• Processed D-SNP applications for enrollment received via Paper with Field Sales Agent assistance, Telephonic, Web, iPad, CMS Portal and OEC - Online Enrollment Center submissions received via Facets Enrollment Administration Manager Workflow (EAM) system.
• Reconciliation of all daily, weekly and monthly Medicare reports generated from CMS.
• Researched and resolved enrollment discrepancies identified as a result of company and MMR report and Horizon records.
• Directly responded or supported a response to inquiries that were rapid and professional to internal and external customers, not limited to Medicare Beneficiaries, Federal Regulators, Executives and Congress persons.
• Generated and ensured compliance and accuracy of various types of member correspondence specific to retroactive enrollment submission to CMS.
• Called potential subscribers and sent letters to verify membership, enrollment, billing and demographic discrepancies received on applications.
• Updated beneficiary requests for enrollment of premium withholding.
• Ensured monthly that all identified discrepancies resolutions were met with CMS timeframes.
• Prepared case documents for retroactive enrollment updates.
• After completion of Quality Assurance (QA) review released completed applications to CMS as an EAF - Electronic Application File.
• Submitted applications via TriZetto’s Medicare Solutions Enrollment Administration Manager - EAM systems into CMS’ Batch Eligibility Queue - BEQ.
• Made appropriate CMS guided corrections to insure approval and eliminate eligibility discrepancies.
• Verified Member Enrollment and Benefits with the TriZetto MMS process of Facets Group, Subgroup, Class/Plan, Product and Subscriber/Family applications.
• Corrected Beneficiaries application enrollment errors revealed via CMS MaRX, CMS Mismatch Report and CMS Discrepancy Report.
• Audited D-SNP Enrollment Applications Processed by TriZetto, Facets 5.3.

Confidential,Chicago,Illinois

Health Care Claims Specialist

• Processed facility and professional Medicaid, Medicare and Medigap claims according to DST/ Gateway and CMS guidelines.
• Adjudicated Durable Medical Equipment (DME), Anesthesia, Member Not Covered and Provider not found, Radiology, Lab, Pathology, Physical Therapy, Occupational Therapy, Speech Therapy, Chiropractic and Home health claims.
• Manually applied interest to claims paid after the 30 days maximum processing period.

Confidential

Customer Benefit Administration Analyst/ Benefit Configuration Analyst

• Used Benefit Maintenance to xPression (BMX), xPression Revise the Oracle EMC2 xPression Enterprise Edition to host the template and combine supplied large amount of data with the template to create documents Summary Plan Descriptions (SPD) - Benefit booklets.
• Created Merit, Cost Plus and Flexible Spending Group Health and Dental Summary Plan Descriptions (SPD) - Benefit booklets.
• Programmed changes to adjudication tables to ensure accurate and timely pharmacy claim payments.
• Documented pharmacy language in Benefits Online (BOL) for internal, external associates and providers on the company’s website Bcbsal.org.
• Analyzed and implemented corporate benefit plans for Underwritten, Cost Plus and Large Cost-Plus groups.
• Configured systems to process prescription drug claims according to Plan Benefits.
• Implemented Pharmacy benefits for Health Care Reform Preventive and Contraceptive mandates.
• Analyzed, interpreted and configured pharmacy benefits based upon group enrollment agreements and business requirements.
• Updated existing benefits with the 2014 Health Care Reform Preventive and Contraceptive mandates.
• Created new riders and update existing pharmacy benefit configurations with Prime Therapeutic Benefit Edit Tool (BET).
• Configured New Pharmacy benefit packages in compliance with the Affordable Care Act prescription drug preventative care requirements and Essential Health Benefit Mandates.
• Configured systems to process health and prescription claims to ensure accuracy of claims processing, benefit plan implementation and compliance with healthcare reform.
• Configured benefits to insure accurate claims processing of member deductible, cost sharing and maximum out-of-pocket amounts.
• Partnered with key stakeholders to identify and resolve any critical issues found as well as query the corporate systems to analyze data of current processes for improvement.
• Answered “Client clarifies” and “Client notifications” and verified new Pharmacy benefits test results.
• Tested plan benefits and rider updates to determine the accuracy of prescription drug codes, quality results and verification for release.
• Transition tested claim lifecycle test execution, claim lifecycle test planning to validate accurate enrollment flow, nomenclature basics on ID cards, drug cost validation and claims processing.
• Reported test results back to Prime Therapeutics and Pharmacy Benefit Manager (PBM).

Confidential

Plan Profile Configuration Analyst

• Implemented plan to plan reciprocal and standard pricing agreements for BlueCard National accounts via the Confidential -Plan Teleprocessing System (ITS) Facets 3.3.2.
• Configured, revised, created updates, rejects and cancellations of Plan Profile Financial Agreements.
• Audited, coded and performed Quality Assurance on new and existing BlueCard Plan Profiles for accuracy.
• Configured changes to Host/ Local Plan Codes and Group Prefixes for all Plan Migrations.
• Cancelled Host/ Local 3 Letter prefixes and plan codes for a Confidential Plan shutdown.
• Configured and submitted Standard financial agreements to the Confidential Association.
• Monitored and maintained Home/Control and Host/Local Plan daily report.
• Updated SharePoint Matrix detailing the completion of Home/Control and Host/Local Plan Profiles.
• Emailed the National Accounts Marketing Department Analyst and Claims Department Manager when the Plan Profile financial agreements were completely configured in mainframe.
• Updated the Claims Division Support and Analysis (CDSA) shared drive Matrix with all Plan Profile Financial agreement completions, migrations, prefix and plan shutdowns.
• Filed all completed Plan Profile financial agreements for future reference and Auditing availability.
• Attended weekly (CDSA) Claims Division Support and Analysis Staff Meetings and Monthly Department Joint Staff Meetings to discuss the progress of All Projects including the Healthcare Reform Act initiatives.

Claims Processing Analyst

Confidential

• Processed Ancillary claims clinical laboratory, durable medical equipment and specialty pharmacy.
• Participated as a Project team member in (CDSA) Claims Division Support and Analysis Department.
• Resolved claims processing issues via the Confidential -Plan Teleprocessing System (ITS) and the BCBS Association guidelines.
• Pulled claims to test the quality of the Plan Profile prefixes for the Blue2 software release.
• Reduced Ancillary Claim suspense by 75 % as associate’s quarterly Performance Improvement Plan (PIP).
• Reduced BlueCard ITS claim volume on Ancillary Provider Filing Post Implementation claims.
• Increased adjudication and updated stop tables on clinical laboratory, durable medical equipment and specialty pharmacy claims.

Confidential

Claims Division Support Analyst

• Updated stop tables allowing claims to adjudicate in compliance with the Health Care Reform guidelines for Women’s Preventive care.
• Researched and resolve defects encountered during various testing cycles in the HP Application Life Cycle Management (ALM).
• Conducted gap analysis with use analytical skills to identify root causes and solutions that were cost effective in assisting with problem management and met business requirements.

Confidential,Chicago,Illinois

Customer Care Representative

• Responded to customer questions via telephone regarding insurance benefits, provider contracts, outstanding inquiries, membership eligibility and claims status.
• Administered HMO, PPO, HSA, POS, EPO, FFS and Medicare Supplemental (Medigap) contracts.
• Assisted callers with claims and benefits on Group, Individual, Special Accounts, Healthy Families, All Kids State Plans and Medi-Cal contracts.
• Analyzed each caller’s problems and provided the appropriate information and solutions.
• Performed research and analysis on behalf of members, providers, group administrators, and brokers.
• Provided research and status on health, dental, vision and pharmacy claims.
• Received and placed follow-up telephone calls to answer customer questions that required research.
• Developed and maintained positive customer relations with internal associates to ensure customer requests were handled appropriately and within a timely manner.
• Documented the outcome and method of resolution of inquiries for future reference, tracking and analysis.

Confidential,Columbus,Ohio

Medicare Analyst Customer Service

• Educated providers on the Centers for Medicare & Medicaid Services guidelines for claims, Medicare Part B benefits and all Medicare Part B services.
• Provided providers with benefits for Medicare Part B Beneficiaries.
• Assisted providers with the reason why their payments for Original Medicare claims were denied.
• Instructed providers how to file for reimbursement and the eligible for their Medicare incentive bonus.
• Advised providers in detail the reason for their Medicare Refunds Requests.
• Advised providers how to dispute and submit Medicare appeals regarding refund requests.
• Instructed providers how to accurately complete the Medicare Provider Enrollment application on the Confidential Medicare website and the CMS PECOS System.
• Explained to providers the steps to correct problems with Edi electronic claim filing and denials.

Confidential,Grafton,Wisconsin

Technical Support

• Provided Technical support to administrations during dental implementation release of Windward software.
• Provided client support on system use and technical issue resolution via E-mail and phone.
• Assisted Dental providers install the Web Portal Windward including administrative applications.
• Assisted providers Pre-register on the New Provider Web Portal.
• Provided troubleshooting and identified why providers were not able to access the Portal.
• Assisted providers locate and install a compatible Internet Browser to gain system access.
• Configured software to allow connection to the Internet application Server.
• Educated providers how to submit their claims using the Windward system.
• Trained providers on the Windward system to verify patient’s benefits, patient’s eligibility and view their remittance payments and fee schedules.
• Educated providers on how to use the Provider Portal Administration Guide and the Provider Portal User Guide self- service tools for future reference.
• Unlocked provider passwords and reset passwords when their current passwords were unknown.
• Escalated calls to level 2 Tech Support when further diagnosis was needed to resolve problems in accessing the Web Portal.
• Resolved inquiries about claim payments, patient enrollment, claims details, referrals and authorizations.
• Searched database and located correct member Id numbers for claims denied as “member not found.”
• Answered provider’s remittance and claims questions.
• Interpreted and communicated subscriber’s Medicare and Medicaid Dental benefits to providers.
• Communicated to providers their reimbursement methodology and contract terminology.
• Made claim adjustments and resubmissions when applicable.
• Researched claim dispositions and interacted with other departments to promote adjudication.

Confidential,Corona,California

Senior Advantage Medicare Member Services Representative

• Advised members, providers, brokers and group administrators of member eligibility, benefits, exclusions and limitations on the Senior Advantage Medicare Replacement Plan.
• Assisted callers with Medical benefits on the Medicare Advantage Healthcare Program (MA) and Pharmacy on the Medicare Advantage Prescription Drug Program (MAPD).
• Advised of Medicare Advantage MA and MAPD claim status, payments and denials.
• Scheduled, changed and verified member appointment dates in the Epic Cadence system.
• Updated, changed and advised members of their primary care physicians.
• Transferred members to their local Confidential facility and applicable physicians.
• Gave members the information to contact their local facility and primary care physicians.
• Assisted members with billing and posted payments using checking, credit and debit accounts.
• Explained enrollment eligibility requirements and rates to new and potential Senior Advantage members.
• Verified Medicare Late enrollment penalties according to CMS Medicare Part D guidelines.
• Verified members’ enrollment in the Special Needs Plan with coverage in Medicare and Medi-Cal.
• Completed the Social Security Administration Extra Help application for member enrollment in the Medicare Part D Low Income Subsidy.
• Documented caller’s complaints and compliments for Case Examiners follow-up and resolution.

Confidential

Customer Care Associate

• Explained contract benefits, exclusions and limitations on health, dental, vision and pharmacy plans.
• Assisted providers, members and group administrators with claim denials and adjustments, Facets 4.7.1 System.
• Assisted members with payment history, billing status and account status.
• Assisted callers with Medical, Dental, Vision and Pharmacy claim status, payments and refunds.
• Sent written correspondence regarding member eligibility status and the outcome of detailed research.
• Reset and gave new passwords to members who were unable to access their accounts.

Confidential

Customer Care Representative BlueCard National Accounts

• Advised the caller of Claim status, payments and denials on BlueCard ITS Home and Host claims.
• Documented the methods of resolution for further reference, tracking and analysis on every call.
• Assisted providers with status on ITS - BlueCard National Account claims.
• Sent ITS serfs to the member’s home plan for claim status and information needed to process claims.
• Sent Submission format (SF), Disposition format (DF) and Notification format (NF) between member’s home plan and host plans to obtain a Reconciliation format (RF) claim payment or denial.
• Verified pricing on facility and professional claims including inpatient Drg and Per Diem pricing.
• Trained, coached, mentored and developed new Customer Care Representatives.
• Wrote and sent letters to provider to inform of the results of research determined after the initial contact.
• Requested provider check tracers when the reimbursement was not received within a timely manner.
• Transmitted Blue2 messages to the member’s home plan to resolve claim payment issues.
• Called member’s home plan to handle claim issues that were not resolved in a timely manner through a Notification format (NF) or in Blue2.

Confidential

Customer Service Enrollment Representative Member Services

• Assisted callers during Open Enrollment with questions on Medicare Supplement and Replacement plans.
• Provided Security/Senior Medigap/ Medicare Supplement, Medicare Replacement members with Premium, Payment, Billing, Enrollment, Eligibility and Benefit Information.
• Assisted Providers with Federal employee’s benefits and claim status, FEP.
• Assisted members with their Federal employee benefits, claim status, address and name changes.
• Mailed benefits packets for Security/Senior Medigap, Medicare Supplement and Medicare Replacement plans to current and potential customers.

Confidential,Florida,Florida

Customer Care Representative

• Quoted medical benefits to providers and members via the Diamond System, Siebel and Convergence.
• Advised providers and members of claim status, payments, denials and delays such as medical review.
• Verified member’s eligibility status, effective dates and termination dates of coverage.
• Documented calls and the methods of resolution for future reference, tracking and analysis.
• Drafted and sent letters to providers and members when issues were resolved after initial telephone contact.

Confidential

Customer Service Specialist

• Assisted Customer Service answer questions on Legacy contracts during the Facets Implementation.
• Quoted benefits and claim status on Legacy contracts prior to their conversion to the Facets system.
• Assisted the Central Migration team answer benefits and claim status questions on contracts converted to the Facets system.
• Documented the caller’s inquiry and methods of resolution.

Confidential,Wisconsin

Customer Care Representative

• Answered questions on member eligibility, benefits and claim status.
• Used P/C image station to produce requested documents and forwarded them to the members.
• Sent letters and made follow-up callbacks to members when issues were resolved after the initial call.

Confidential,Dallas,Texas

Provider Maintenance Implementation Representative

• Configured and accurately formatted Provider contracts into the PIMS payment system.
• Eliminated duplicate and terminated provider payment information in the company’s database.
• Updated provider tax id numbers, billing information, fee schedules and preferred agreements.
• Loaded new demographics and verified that current demographics were accurate on all providers.
• Edited and updated provider information for publication in the Preferred Provider Directory.

Confidential,Woodland Hills,California

Customer Care Representative

• Administered HMO, PPO, HSA, POS, EPO, FFS and Medicare Supplemental (Medigap) contracts.
• Assisted callers with claims and benefits on Group, Individual, Special Accounts, Healthy Families, All Kids State Plans and Medi-Cal contracts.
• Quoted medical, dental, vision and pharmacy benefits to members, group leaders and brokers.
• Advised of claim status, payments and denials.
• Verified and gave members’ eligibility status, effective dates and termination dates of coverage.
• Coordinated and updated benefits with Medicare and other insurance carriers.
• Changed member’s HMO Primary Care Physicians and IPA Medical Groups when requested.
• Sent letters or called the customer when problems were resolved after initial contact.
• Documented calls and the method of resolution for future reference, tracking and auditing.
• Requested check tracers and reissues when payments were not received within a timely manner.
• Processed appeals and grievances when members disagreed with claim payments and denials.