CAREER SUMMARY:

Experienced Healthcare Analyst that accepts the responsibility to support both external clients and internal management, who has 20 years of claims administration and auditing with an emphasis on Confidential Managed Care Fraud, Waste and Abuse, analyzing outliers and designing recommendations including workflows, processes and procedures. Experience in creating Business Vision Documents, Business Requirement Documents, and Functional Requirement Documents. In depth experience with the judiciary system related to pretrial forensic evaluations ordered by the adult criminal courts of Maryland. Knowledge of ICD - 9, ICD-10, CPT and HCPC Coding.

PROFESSIONAL EXPERIENCE:

Confidential

Project Manager

Responsibilities:

• Determined purpose of Forensic Database, defined objectives through consultation with staff at all levels
• Ascertained the client’s needs by gathering information to be recorded in the database and effectively communicate them back to the client
• Developed understanding of the Judiciary Process and services provided for individuals with mental health disorders and developmental/intellectual disabilities who are court-involved.
• Created and updated Business Vision Documents, Business Requirement Documents, and Functional Requirement Documents.
• Assisted with database design and development ensuring that database met user requirements
• Provided database end user training and technical support
• Produced written documentation and training manuals
• Created a quarterly Newsletter for the end user
• Managed database access with log on/user access

Staff Consultant

Confidential

Responsibilities:

• Reviewed Business Plans for New Program applicants validating state standard requirements are present
• Participated on Compliance Committee for a collaborated view of provider activity, identify potential fraud, waste and abuse, make recommendations and to establish course of action
• Coordinated with Maryland Confidential to revise the Confidential Manual
• Coordinated with Maryland Confidential to analyze and render final decisions of non-clinical appeals/complaints according to procedure, state and federal guidelines

Confidential

Analytic Specialist

Responsibilities:

• Identify payment errors by thorough investigation of medical claim data and records.
• Collect additional data as necessary to evaluate request applying appropriate clinical criteria.
• Visit provider site to perform on-site claims audit
• Evaluate audit findings and customer processing guidelines.
• Update audit findings with the management and assist in error validation process.
• Conduct Provider calls for the purpose of recovery of overpaid claims

Confidential

Analytic Consultant

Responsibilities:

• Modify or customize analytic project templates
• Interpret key analytic findings
• Draft presentations of analytic findings
• Estimate level of effort for proposed projects
• Interact with clients and respond quickly to client requests
• Provide on-site and/or telephone support (e.g., client inquiries, requests for ad hoc reporting assistance, miscellaneous research, advice on analytic methods) and training to client end users

Analytic Consultant

Confidential

Responsibilities:

• Education and Training - assisting end user with information on changes to the Confidential & Confidential eligibility forms and how to access and use the PDF repository
• Planning and Analysis for State Readiness Assessment; Confidential - Confidential & Confidential eligibility forms template conducting preliminary testing to verify TEXT in PDF matching TEXT in template, identifying errors in punctuation, grammar and readability
• Testing MACPro Forms for accuracy and accessibility, ensuring that all prompts work and that all links connect to the appropriate “next” phase.

Analytic Consultant

Confidential

Responsibilities:

• Responsible for new algorithm development, for 24 states, from concept, design and specifications to final findings reports using data analysis for detecting Confidential waste, fraud and abuse to be used in making recommendations to the client.
• Research state policies, Federal and State laws and other documentation to gather appropriate and accurate information to prepare final findings reports for presentation to the CMS
• Prepare documentation on concept and development of an algorithm and present to peers for feedback
• Research all available coding resources to gain accurate information for identifying potentially inappropriately paid claims.
• Identify, create and report analysis on estimated overpayments.
• Clarify scope and design issues, communicate status and results, develop appropriate deliverable documentation.
• Perform outreach to subject matter experts to obtain information for developing new algorithms
• Identify new ideas for the creation of algorithms and data models to detect incorrect or fraudulent Confidential billings

Confidential

Business Analyst

Responsibilities:

• Created documentation and reporting specifications to set up an effective audit process.
• Developed and implemented policy and procedure guidelines and reporting specifications for Compliance & Fraud and Abuse detection, investigation and prevention.
• Created and maintained audit retractions logs, payment plan logs, and claims payment withholding logs.
• Created demand letters and developed and monitored structured payments by providers, providing consultation to management and State. Including submission to The Central Collections Unit ( Confidential )
• Researched the policies of the company, state and federal laws, State Program policies, and OIG reports in order to develop the APS Healthcare/MAPS-MD Compliance Manual.