SUMMARY:

• 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
• TEMPeffective working solo is in search of a challenging position that will utilize their skills to its full potential.

PROFESSIONAL EXPERIENCE:

Confidential

Sr. QNXT Consultant /Project Manager

Responsibilities:

• Confidential 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 wif the ability to clearly communicate technical concepts
• Streamline, consolidate and create clinical workflow, and/or healthcare information technology wifin QNXT and 837/EDI solutions
• Facilitate implementation of projects by conducting conference calls, webinars, and meetings and act as a primary contact of client’s questions through project and theirafter 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 wif 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 wif system implementations, conversions, service releases updates and patches, and transition management
• Assist health plans wif 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.

Confidential Houston, TX

Configuration Analyst II

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 TEMPeffectiveness and quality care.
• Problem solve wif Health Plans to ensure all end to end business requirements has been documented.
• Works wif internal and external stakeholders to understand business objectives and processes associated wif 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 wifout instructions using attained business knowledge which is applied consistent wif current configuration and operations.
• Participates in defect resolution for assigned component.
• Assists wif 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 table information into computer system(s).
• Conduct Unit Testing when appropriate. Works wif 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 wif 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 TEMPeffective 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 wif TriZetto on system testing and resolutions
• Corrected and edited manuals for Utilization Management that was initiated and administered by TriZetto.
• Lead trainer in Utilization Management departmental for QNXT implantation.
• Create step-by-step refresher materials for staff to meet legacy system transition to QNXT Go-live.
• Assisted wif 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 wif External Links created to correlate wif 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 wif 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 wif CHC/health Plan.
• Deliver exceptional customer service by embracing Confidential County Hospital 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.

Confidential Houston, TX

Access Representative II

Responsibilities:

• Perform insurance benefits verification in accordance wif 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- and obtains authorizations/referrals as required by payer guidelines and in accordance wif company policy.
• Initiate pre- and authorizations wif Med Solutions, AIM and/ and or other providers for high dollar procedures and surgeries.
• Evaluates Confidential ’s financial status and establishes budget payment plans. Follows and reports status of delinquent accounts.
• Identifies and resolves Confidential billing complaints. Prepares, reviews and sends Confidential 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-s, and authorizations.
• Perform administrative duties including but not limited to filing, data entry, and upfront collections.

Confidential Houston, TX

Access Representative II

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-, authorizations and/ or RQI’s for MRIs, CAT scans, PET scans, Nuclear Medicine procedures, Inpatient & Outpatient surgeries.
• Verify details of insurance coverage wif private or governmental carriers based on CPT and ICD9 codes.
• Provide Confidential financial responsibility to patients prior to medical services being provided & pursue upfront collections.
• Verify authorization and pre- 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 wif Insurance Companies and wif other departments wifin Confidential .
• Perform other duties as assigned by management & assist on special projects.
• Enforce HIPPA laws and protect Confidential information.
• Performs daily administrative duties including (but not limited to) maintaining Productivity, maintaining several reports as needed by Department, Management, and/or Executives, etc.