QUALIFICATIONS SUMMARY

• 10 years in a managed care/healthcare organization.
• 10 years of knowledge with medical privacy laws, clinical research, insurance data entry, customer service, and pharmacy related information.
• 9 years of knowledge for Center for Medicare Medicaid Services.
• 8 years of claims processing, medical collections, adjustment audits methodology.
• 8 years of hospital inpatient and outpatient claims processing and understanding of medical terminology.
• 5 years of academic or relevant work experience to strongly demonstrate the following skills and knowledge: Data analysis, statistical analysis, communication skills, analytical skills, interpersonal skills and group facilitation skills.
• Knowledge of Medicaid data flow, claims data, eligibility and enrollment principles.
• Knowledge and experience in the areas epidemiology and/or statistics in a public health agency or research setting.
• Proficient skill level with SQL Queries, Data Mining, Data Modeling, CMS PECOS, and Data Management skills.
• Ability to build advanced integration, functional, performance, and UI automation test framework/suites to exercise the application at respective levels and introduce quality into the product early.
• Ability to build tools to increase engineering productivity.
• Full proficiency in statistical analysis and database management using statistical programs e.g., SAS and database software e.g., Excel, Access .
• Knowledge and understanding of HIPPA, Pharmacy Laws, Department of Health, HCFA, DEA, State Bureau of Narcotics, JCAHO, FDA.
• Maintains a high level of work quality, and works well with others.
• Strong analytical and organizational skills.
• Excellent verbal and written communication skills.

EXPERIENCE

Confidential

• Conducting HIV testing, and assisting different education forums at key outreach locations.
• Conduct scientific based prevention education sessions with HIV positive individuals, and individuals at risk for HIV infection, including individual sessions, workshops, and social marketing activities for on-going recruitment.
• Implement interventions focusing on HIV risk reduction and provide HIV prevention education through social support strategies within the community.
• Assists in development of community partnerships to enhance and optimize resources in advancing HIV prevention testing initiatives.
• Works closely with EIS and other staff outreach workers to ensure standardized continuity of referral and linkage to care, prevention and social services for newly diagnosed or lost to care clients.
• Provide specialized HIV prevention education to HIV positive individuals, including individualized sessions and educational workshops.
• Coordinate and implement all program activities as per scope of work and timeline.
• Prepare and develop all program curriculums, materials, fliers, and all other printed materials required by the program or based on patient's needs.
• Coordinate with the Director of HIV Prevention and Health Education.
• Coordination and assist in all client conferences, workshops and medical updates.
• Collect data, conduct data entry and prepare monthly program statistic.

Confidential

Triage Clinical Research Date Intake Specialist

• Medicare and Medicaid Clinical Analyst.
• Appeals and Grievances coordinator.
• Clinical Research and Medical Review.
• Responsible for the management of designated clinical trials including investigator selection, analysis of potential patient recruitment, preparation of trial related documentation protocols, Case report forms, investigators brochures, consent documents, letters of agreement, confidentiality agreements , organizing.
• Review provider claims and clinical information for pertinent data and facts to identify and solve a range of appeals.
• Research and Review medical claims and data in COSMOS, CSP Facets Platform, Diamond platform, ORS, Facets Unisom, and UNET.
• Research, identify and obtain data/information needed to help process claims or resolve claims issues e.g., verify pricing, prior authorizations, applicable benefits .
• Utilize research methodology and data collection tools to ensure that appropriate data is gathered.
• Analyze medical utilization rates of specific providers and/or across physician, hospital and ancillary service lines.

Confidential

Claims Validation Analyst

• Support business owners and senior leadership through the use of problem solving skills and analysis of the information to help identify issues and solutions.
• Performs direct data pulls and report writing in a manner that is clear, concise and representative of the requester/business owners needs and objectives.
• Medicare parts A, B D, and Medicaid insurance.
• Medicare/ Medicaid Reimbursement methodologies.
• Project Management: ability to coordinate multiple tasks and lead assigned projects to stated objectives
• Assisting with routine data analysis and interpretation using data analysis programs.
• Review billing comparisons in Medicaid and Medicare to investigate aberrancies.
• Make potential fraud determinations by utilizing a variety of sources such as the Contractor's internal guidelines, Medicare and Medicaid provider manuals, Medicare and Medicaid regulations, and the Social Security Act.
• Develop and prepare potential Fraud Alerts and Program Vulnerabilities for submission to CMS.
• Prepare medical audit information for patient's hospital.
• Recovery Resolution and payment identification.
• Data analyst strategies, medical cost containment programs, and special projects that directly impact the operational and financial performance of network management using strong reporting, and analytics.
• Analyze medical utilization rates.

Confidential

Clinical Pharmaceutical Technician Health Insurance Data Specialist

• Supports and coordinates registration and dispensing activities associated with special handling mediations that require patient registration, provider registration, and coordination with specialty pharmacies.
• Researches and resolves all billing system related issues.
• Appeals Grievances involving medical necessity, retroactive authorizations, prescription drug coverage, and/or member eligibility.
• Monitor and evaluate state Medicaid programs for compliance with Federal regulations. Staff provides advice about the law, regulations, and policy in such issue areas as eligibility, coverage and payment.
• Provide specialized pharmacy services for investigational drug management.
• Provided educational services to healthcare providers, pharmacy staff, and patients requesting access to specialized medications.

LICENSES CERTIFICATIONS

• Tennessee Registered Pharmaceutical Technician.
• Georgia Registered Pharmaceutical Technician 2013-current .
• Certificated in HIV testing, prevention, education specialist April/ 2012-current .

SKILLS

Operating Systems:

• Proficient with Windows 98/2000/NT/XP, Windows 7/8, UNIX, LINUX

Proficient with the following Applications:

• Productivity software Microsoft Office, Microsoft Works
• Word processing Database/File management Access, FileMaker
• Spreadsheets Excel
• Presentation software PowerPoint