SUMMARY:

• My current responsibility as a Project Manager for Process Improvement manages and supports the development of new or improves process throughout the Army Headquarter MEDCOM Business Office. My position working in an information Technology environment where I lead several a project consisting of design and build a solution that creates and enhances the business flow operations. Experienced Project Manager with five - year’ experience in project planning, implementation and execution and proven ability to support multiple projects with medium to high complexity. Part of my responsibility was to enhance SharePoint and build programs applications so that the data is visible and accessible to the entire MEDCOM Headquarters. I have a keen knowledge of Microsoft project and office; Information Technology application, systems, and processes; Resource Management policies and practices and change management techniques with an ITIL and Six Sigma Methodology.
• Prior experience helps team developers, and other department heads, testing, troubleshooting. Experience with IBM Rational Concert Configuration and Change Management; Rational Quality Management, Rational DOORS Next Generation Requirements Management; Excellent Knowledge in ANSI and X12 Standards and HIPAA. Familiarity with XML standards SQL, SAP, SAS platform, Visio, and Service Desk Manager (DSM) ticketing system; clear understanding of 277, 278, 834, 835, 837, 810, 850, and 856; WAP, TA1/999, 277CA. A strong understanding of HIPAA and EDI solution for clients’ eCommerce, health and financial claims management, eligibility, provider, and reporting.
• Consistently achieving high satisfaction rankings, and over performing turnaround times and a respected team builder and leader with a customer-focused team; installs a shared, enthusiastic commitment to customer service internal and externally. Uses time effectively to ensure that business operation assignments are complete. Develop procedure policy improvements with an ITIL and Six Sigma Methodology. I have also taken key roles in improving compliance and according to policy. Participate in SWOT, incident/ critical incident management, and disaster recovery. I handle special projects and SME of the following tactics: mentoring, directing,, supervising overall department functions and staff of customer service operation, giving personal interaction, and resolving varies complex issues and employee disciplinary action as necessary and the following levels of Health Care:

PROFESSIONAL EXPERIENCE:

Confidential

Project Manager Consultant/Contractor

Responsibilities:

• Responsible for management of all phases of client service projects in areas of information technology and business systems engineering and refining data solutions
• Defined and documented business requirements and business processes with an understanding of data management implementation.
• Works closely with cross-function teams and resources to accomplish program goals and milestones within the scheduled time established. Also, managed project closing and ensured project deliverables achieved cost and scope
• Developed project plans identifying key dates and resource requirements by gathering and refining the requirement for data management capabilities such as informatics software Enterprise Data Lakes
• Assembled and directed project teams of 10 members
• Defined and controlled project budgets of up to $250,000
• Tracked key milestones, adjusted project plans accordingly and implement project design.
• Prepared and delivered reports and recommendations
• Worked Federal contracts as Medicare, Medicaid, and Tricare; coordinating projects, systems testing, installation, and support for several health care providers.
• Work collaboratively with Information Management Staff, Data Management business analyst staff with a goal of providing identity resolution and enhancing governed data.
• Manages risk by establishing project management process (Six Sigma) to address challenges associated with quality, schedule and cost.
• Coordinated plan, manage, analyze, and develop activities for projects to accomplish goals and objectives.
• Communicate with stakeholders and provide insight on issues through root cause analyses

Confidential, Austin, TX

Business/Functional Analyst/Sr. EDI Help Desk Operation

Responsibilities:

• Process the EDI transactions using the Accredited Standards Committee (ASC) X12 standards, the National Council Prescription Drug Programs (NCPDP) standards, and the Health Level 9 (GS9) protocol.
• Document customer service issues, according to procedure
• PM for special projects/program to resolve challenges associated with the quality and cost of day-to-day business functions.
• Understanding health insurance portability and accountability act (HIPAA) compliance policies
• Experience with CPT, HCPCS and ICD codes;
• Advanced in Microsoft Office
• Perform triage and first resolution for production problems and communicating with change requests.
• Troubleshooting and resolution, using storyboards modeling eCommerce pharmacy and financial claims
• Analyzed Data, structure trending flow charts, SAP reporting, SAS VirtualBox platform, Visio and Service Desk Manager (DSM) ticketing system management.
• Managed Care System (MainFrame)
• Serve as a subject matter expert, ensuring visibility to project teams by monitoring and reporting business objects, and project
• Experience with IBM Rational Concert Configuration and Change Management; IBM Rational Quality Manager and IBM Rational DOORS Next Generation Requirements Management.
• Gather data and analyze trends/patterns affecting quality/SQL
• Disseminate the work to Team members.
• Developing documentation and demonstration content of enhanced functions for end users
• Qualitative and Quantitative data Confidential
• Log all Requests for Change (RFC) in Tracking System for Requests, Issues, and Projects application (TRIP).
• Maintain VA-FSC EDI Team group mailboxes.
• Producing the Weekly Status Report, the Weekly Customer Report, and the Monthly Customer Report
• Monitor inbound and outbound email to review response quality, and customer satisfaction
• Reports about performance and quality assurance issues for consideration;
• Serve as a communication hub for external customers and payers for all incoming RFC.
• Distribution of project amongst ECD department
• Act as a buffer between the Production Team and smaller production issues quickly resolved by a first level agent.
• Confidential data by accessing various software; Mainframe, UltraEdit, TSM (ticketing system management)
• Special projects as requested creating data charts and tables as directed by the CEO and other management teams;
• Monthly financial and medical data audits before giving to IT/ECD Chief Operation Executive

Confidential, Austin, TX

Patient Account Specialist II

Responsibilities:

• Reviews aging accounts on a weekly basis finds and resolves problems related to the file and reports inconsistencies; also,
• Follow up with insurance companies to ensure prompt receipt of payments and proves the ability to discuss insurance-related issues regarding sensitive financial matters and recapture unpaid balances.
• Review EOBs, and COBs, to ensure proper reimbursement
• Participate and keeping Payer’s manuals and profiles
• Prepares to write off request with proper documentation, insurance, and patient correspondence that includes denials and paid promptly;
• Review and Confidential claim submissions to ensure the correct benefit determination as well as the accuracy of payment.
• Researchers Medicare reimbursement policies and guidelines for every service type, including DME, and decides Medicare Part C payment disputes with well-supported written decisions.
• Assisted in the development of the automated case tracking system
• Trained co-workers on how to make and prepare decisions
• Communicated with other providers/insurance companies in handling disputes via telephone

Confidential, Austin, TX

EDI-System Administrator

Responsibilities:

• Completing and submitting EDI/ERA agreements to clearinghouses and payers;
• Ensuring modules processed in the Tiger Misys System; Ensure claims such as EOB’s, electronic data, and appeals
• Sort HCFA’s to proper carriers
• Print and distribute paperwork daily
• Pull weekly reports and closed companies daily
• Special projects as needed
• Reviewing and correcting rejection claims
• Assist VP with month end balancing and closing
• Analyze employer group information to identify commercial, government, and self-funded claims
• Monitor staff levels to ensure business needs based on the business guidelines.
• Strong knowledge of EDI 834, 835 and 837
• Experienced in XML and XSD
• Understanding of credentialing process; and process payers’ enrollment for EDI submission
• Set up new provider in the database and make sure that credentialing paperwork was for Medicare approval.
• Provide feedback and ongoing for staff and management related to job functions
• An advanced understanding of medical benefits, for example, HMO, PPO networks, Medicaid and Medicare plans.
• Extensive with Medical terminology, CPT, REV UBE84, and HEFA claim forms
• Experience in Confidential, verbal, and written communication; for application inquiries for plans, and staff.
• Maintaining changes update and notification required by clients
• Understanding of regulation statutory guidelines, HIPAA, and the Affordable Health Care Act

Confidential, Austin, TX

Specialty Pharmacy Coordinator

Responsibilities:

• Advanced understanding of health care plans, Chip, Foster Care, Medicaid, and Medicare plans, Medical Terminology, CPT, REV, UBE84, HEFA claim forms, and ICD 9 codes and referral PA processes.
• Run application reports through provider information system Amysis and distributed daily workflow.
• Assist Pharmacist with utilization review in compliance with health plans, corporate and state policies, and the company’s procedures, and guidelines.
• Documented result of decision through CCMS, and Amysis portal
• Collaborate with management, team members, and pharmacist’s staff to provide resolution related to issues and concerns; help support members about formulary changes as, NDC, not covered matters, new client implementations, initiating referrals, prior authorization processing to ensure all documentation received to process a claim efficiently .
• Review and Confidential claim submissions to ensure the correct benefit determination as well as the accuracy of payment.
• Analyze inquiries requesting supporting documentation to conclude the claim payment while verifying accuracy and ensuring timely filing.
• Communicate with vendors and providers to obtain additional information to complete reviews, making appropriate claims adjustments when necessary.
• Prepare written responses indicating missing information as well as claims denials and actions deemed essential for redetermination.
• Assist with resolving difficult issues with both internal and external customers.
• Verify coding is appropriate with procedure and according to eligibility requirements
• Proactively address rejections as it relates to the clinical and specialty department
• Coordinate operational performance guarantees and work clinically-related pharmacy queue for clinical resolution related to retail, specialty pharmacy issues, and member issues
• Review and thoroughly investigate denial claim and determine the appropriate course of action for resolution promptly and follow-up denial claims
• Create and send approval or denial letters as stated as required Handle change request to member eligibility, add-ons, and terminations as identified by the client.
• Document and identify potential eligibility issues and notified the appropriate party to resolute, customer enrollment in benefits changes.

Confidential, Austin, TX

Integrated Claims Examiner

Responsibilities:

• Assist in and supervised lower level employees
• Complete utilization reviews of cases by guidelines and regulations and document assessment
• Close interaction with employee, client, and physicians and assist with job coach in making recommendations for returning workers back to work full duty or no less than r/ L's
• Provide direct oversight of claims processing activities in meeting production, deadlines, and quality standards.
• Communicate with other departments to enhance employee return to work speedily
• Document correspondence and determination of review according to SOP and State requirements
• Implement approval and denial documentation for employee and record system for clients as required
• Quality control and improvement
• Initial assessment of the denials via phone and determine the appropriate course of action for resolving rejected claims in a timely manner
• Collaborate with other departments with turning around the underperforming area. Train CSRs significant improvements for client satisfaction and productivity.
• Respond to correspondence and inquiries within turnaround time of 24 hours after request
• Medical necessary decision-making using some local and national coverage determination guidelines for BME and inpatient, outpatient clinics and extremely complicated or unusual claims
• Reviewed new and audited existing requests for determination of benefit eligibility and meeting policy processing deadlines

Confidential, Austin, TX

Senior Claims Benefits Analyst

Responsibilities:

• Supervised, trained, and supported quality work ethics
• Analyze accuracy of ICD-9 and HCPCS Codes used to send claims for payment for the reimbursement on the explanation of benefits (EOB) and coordination of benefits (COB)
• Verified for correct codes and bundling rules used for claims and payments reimbursed by billing and coding guidelines
• Understanding of the complete healthcare revenue
• ICD-9 and new plan implementation; interface with clients to understand their needs and configuring software to meet those needs; running usability of testing for readiness, and create a procedural manual based on the need of the client
• Audit medical billing claims via manual from US mail or electronically using payment data forms and practice management systems;
• Manufacturing processes and procedures
• Resolved rejected claims
• Analyze employer group information to identify commercial, government, and self-funded claims
• Complete understanding of medical and pharmacy benefits as, HMO, PPO networks, Medicaid, and Medicare plans.
• Extensive with Medical terminology, CPT, REV UBE84, and HEFA claim forms
• Extensive experience and Confidential, verbal, and written communication, for application inquiries for plans and staff
• Understanding of regulation statutory guidelines, HIPAA, and the Affordable Health Care Act

Confidential Orlando, FL

Provider Relation Resolution Supervisor

Responsibilities:

• Supervised daily workflow of the provider relations functions in compliance with health plans, state policies, procedures, and company guidelines
• Work as a release person as needed in the absence of Senior Benefits Management
• Collaborate with corporate to obtain a manual check based on reimbursement per client plan
• Document provider interaction monitored the Provider Relation queue by e-gain web and respond with 24 hours of notification.
• Coordinate and participate in meeting with providers to conduct orientation, educating providers on claim policies and procedures, delivering written material, or contracting with our health plan's network.
• Understanding of the complete healthcare revenue cycle
• Run application reports through the provider information system,
• Handle change request for member eligibility, add-ons and terminations of plans as identified by the client
• Documented and identified potential eligibility issues and notified the appropriate party when resolved regarding customer enrollment and benefits changes
• Worked as a Senior Specialty Pharmacy Coordinator providing medical information and implementing data into a drug safety database
• Maintain patient profile to keep current as possible
• Worked as a Reimbursement Senior Specialist Lead spotting and investigating the details in insurance claims that may indicate insurance coverage abuse, fraud, and unwarranted medical procedures.
• Identify, Confidential, and review problems related to overpaid or unpaid claims
• Reviewed rejected or returned claims and resolved issues related the claims promptly .
• Answered queue inquiries, from medical, pharmacy and customers regarding coverage and explaining rejection related to experimental treatment or controversial procedure.
• Communicated with different department of account billing operation to resolve issues
• Run reports exporting data to produce audits and cost estimates
• Also, worked as Customer Service Representative Lead handling difficult customer calls and complaints, correspondence related to insurance coverage or policy, including eligibility updates as a client request, in additional and supervising junior representatives