OBJECTIVE

• A life - long learner, inspired by attaining and exploiting knowledge to reach goals and organizational benchmarks. A professional that is people and customer-centric; that can execute and direct tasks as a participative team player, yet equally effective working solo is in search for a challenging position that will utilizes their skills to its full potential.

PROFESSIONAL EXPERIENCE

Confidential

Sr. QNXT Consultant /Project Manager

Responsibilities:

• Meet with clients to identify opportunities and strategic goals to standardize or steer clients toward new services and products that enhance or improve their business needs
• Proactively lead assigned projects by creating project timelines, identifying milestones and additional resources needed to complete deliverables
• Ensure implementation of new business or program enhancement and deliver on commitment by ensuring a smooth program setup, minimizing operational impact and managing risk through continuous communication and quick resolution of problems
• Leads cross functional teams to drive process improvement initiatives; define project scope objectives; and develop preliminary project plan and design
• Demonstrate strong project management skills and knowledge of principles and practices with the ability to clearly communicate technical concepts
• Streamline, consolidate and create clinical workflow, and/or healthcare information technology within QNXT
• Facilitate implementation of projects by conducting conference calls, webinars, and meetings and act as a primary contact of client’s questions through project and thereafter as needed or as contract permits
• Document processes and business requirements in a clear and concise manner to facilitate operational, IT and reporting setup internally by possessing the technical expertise to work with IT to identify functionality needs to support improved outcomes in Case Management, Utilization Management, Claims, and QNXT Configuration
• Demonstrate understanding of current client processes and modifications needed to achieve client satisfaction and deliverables
• Serve as a resource knowledgeable of the end-to-end impacts of Claims Processing and QNXT Configuration throughout a Managed Care Organization (MCO)
• Assist both start-up and mature MCO’s with system implementations, conversions, service releases updates and patches, and transition management
• Assist health plans with applying accurate payments to providers utilizing appropriate fee schedules, groupers, pricers, contract terms, interest calculations, and provider payment disputes.
• Basic understanding and ability to generate queries and/reports using SQL Server Reporting Services and Integration services.
• Completed assigned daily tasks through HEAT ticketing/tracking system

Confidential, Houston, TX

Configuration Analyst

Responsibilities:

• Analyze by applying knowledge and experience to ensure appropriate information has been provided.
• Thoroughly understand health plan’s environment and how QNXT software can be used to increase efficiencies, cost effectiveness and quality care.
• Problem solve with Health Plans to ensure all end to end business requirements have been documented.
• Works with internal and external stakeholders to understand business objectives and processes associated with the Medicaid enterprise.
• Assist in planning and coordination of application upgrades and releases, including development and execution of test plans.
• Demonstrate ingenuity self-reliance and resourcefulness. Able to take action without instructions using attained business knowledge which is applied consistent with current configuration and operations.
• Participates in defect resolution for assigned component.
• Assists with development of configuration standards and best practices
• Suggest improvement processes to ensure systems are working more efficiently and improve quality.
• Load and maintain provider, contract, benefit or reference table information into computer system(s).
• Conduct Unit Testing when appropriate. Works with technical staff for interface testing, data load validation and other data related tasks assigned
• Apply previous experience and knowledge to research and resolve Utilization Management issues, claim/encounter issues, pended claims and update system(s) as necessary.
• Apply knowledge of interfaces and other applications to research and resolve issues and update system(s) as necessary.
• Collaborate with team members to share experience and knowledge.
• Monitor claims queues to identify issues, makes recommendations, and implements configuration changes to improve claims TAT and accuracy.
• Ability to handle fluctuating volumes of work and be able to prioritize work to meet deadlines and needs of user community.
• Basic understanding and ability to generate queries and/reports using SQL Server Reporting Services and Integration services

Confidential, Houston, TX

QNXT UM & Configuration Team Lead

Responsibilities:

• Resolve and configure solutions for complex issues in an effective and efficient way
• Department QNXT expert and liaison between Claims and UM for fired edits and QNXT errors that resulted in paid claims and auto adjudication
• Work closely with TriZetto on system testing and resolutions
• Corrected and edited training manuals for Utilization Management that was initiated and administered by TriZetto.
• Lead trainer in Utilization Management departmental training for QNXT implantation.
• Create step-by-step refresher training materials for staff to meet legacy system transition to QNXT Go-live.
• Assisted with Provider communication letters for HHSC approval, as well as denial letter and approval UM letters process
• Navigated QNXT demo as UM Lead for HHSC onsite review
• Assisted with External Links created to correlate with QNXT to meet CHC needs outside of QNXT. i.e. Fax Notifications, Denial Letters, Reporting Services

Confidential, Houston, TX

Utilization Management Coordinator

Responsibilities:

• Process inpatient admission, notification of complicated deliveries, sick newborns and other services. Obtain all pertinent information related to the admission, facility to facility transfer, out of network provider, medical record number, route of transport, type of admission, and other key information.
• Answer and handle calls from the Provider Hotline directed to Health Services and Utilization Management for referral/authorization initiation and questions. Answers in a timely and professional manner.
• Help maintain daily census by monitoring pended cases and reporting to appropriate Hospital Case Manager.
• Work collaboratively with coworkers to deliver member/provider services that meet or exceed member/provider expectations as evidenced by annual CHC Provider Satisfaction Survey and Member Satisfaction Survey scores of Overall Satisfaction with CHC/health Plan.
• Deliver exceptional customer service by embracing Confidential District’s Service FIRST standards of behavior during all provider, member, visitor and staff encounters.
• Responsible for printing, correcting, pulling and mailing deadline of Denial letters sent to providers and members.

Patient Access Representative

Responsibilities:

• Perform insurance benefits verification in accordance with company policy for outpatient and inpatient services for the facility.
• Identifying and verifying the payer source to ensure the accurate routing of revenue, follow up by the appropriate hospital personnel and ensure specific billing requirements are met.
• Performs pre-certification and obtains authorizations/referrals as required by payer guidelines and in accordance with company policy.
• Initiate pre-certification and authorizations with Med Solutions, AIM and/ and or other providers for high dollar procedures and surgeries.
• Evaluates patient’s financial status and establishes budget payment plans. Follows and reports status of delinquent accounts.
• Identifies and resolves patient billing complaints. Prepares, reviews and sends patient statements.
• Performs various collection actions including contacting patients by phone, correcting & submitting claims to third party payers.
• Maintains work queue through constant follow up on pending referrals, pre-certifications, and authorizations.
• Perform administrative duties including but not limited to filing, data entry, and upfront collections.

Patient Access Representative

Responsibilities:

• Responsible for making outbound calls to health insurance companies to verify in-network/out-of-network medical benefits and obtain prior authorizations and referral requests for HMO, PPO and POS health plans.
• Obtain Pre-certification, authorizations and/ or RQI’s for MRIs, CAT scans, PET scans, Nuclear Medicine procedures, Inpatient & Outpatient surgeries.
• Verify details of insurance coverage with private or governmental carriers based on CPT and ICD9 codes.
• Provide patient financial responsibility to patients prior to medical services being provided & pursue upfront collections.
• Verify authorization and pre-certification numbers to match the days patients were admitted and discharged in hospital to prevent denial of claims.
• Research eligibility information online and update the hospital Meditech system.
• Act as a mentor to ensure that work of all team members excels in performance standards and meet all departmental expectations.
• Resolves insurance discrepancies by continuously communicating with Insurance Companies and with other departments within HCA.
• Perform other duties as assigned by management & assist on special projects.
• Enforce HIPPA laws and protect patient information.
• Performs daily administrative duties including (but not limited to) maintaining Productivity, maintaining several reports as needed by Department, Management, and/or Executives, etc.