Summary

Results-oriented, skilled professional with 26 years experience in the healthcare data industry. Solid experience in consistently meeting or exceeding established goals and objectives related to data warehousing and analysis. Motivated and ambitious with excellent interpersonal communication and organizational skills---always seeking a new challenge.

Professional Experience:

Confidential

Position: Senior Medicaid Recovery Audit Contractor Specialist

• Research Centers for Medicare Medicaid Services CMS and local billing and reimbursement policies, client reimbursement practices through review of manuals/regulations and meetings with stakeholders to develop and configure improper payment algorithms. Organize, document, and communicate results.
• Apply knowledge of provider billing and patient accounting practices to research of client policy and data to reveal new overpayment recovery opportunities. Work with data miners, clinical staff, and stakeholders to identify new overpayment issues for each client this includes 32 Medicaid RAC clients
• Participate in the review of health insurance claims and member eligibility information to uncover claims overpayment trends associated with non-compliance or misapplication of contract terms and rates, payment policies, medical policies, billing guidelines, and applicable regulatory requirements
• Develop data extract specifications/business rules to select claims not paid in accordance with regulations for IT programming
• Monitor proprietary system used for tracking audits and findings to ensure high degree of accuracy and maximum productivity.
• Report analytic development progress and outcomes to Executive Management, internal and external clients.
• Ensure departmental goals are consistently met or exceeded.
• Review IT programming results for quality assurance and proof of concept validation
• Provide data quality feedback to client and audit team by accessing multiple client specific MMIS Medicaid Management Information System systems
• Document results and support preparation of internal and external documentation and presentations related to research and new overpayment issues
• Work with internal operations, clinical teams and audit relations to develop and implement review/audit/recovery protocols and internal review guidelines
• Track, follow-up and provide staff training on results and recoveries
• Develop and validate workflows and communication tools QTS and OnTime to best enhance audit production, client satisfaction, and quality assurance.
• Work with IT to develop and implement technological improvements that will support the audit process.
• Develop business criteria to maximize the identification of contractual billing compliance audit recovery opportunities.
• Serve as a subject matter expert for coding and billing practices using the following code sets: International Classification of Diseases ICD-9-CM , Current Procedural Terminology CPT and Healthcare Common Procedure Coding System HCPCS
• Contribute new ideas for improving existing audit processes and audit analytics
• Work cohesively with the audit team and the client
• Develop, maintain, and ensure adherence to multiple project schedules

Confidential

Position: Senior Fraud Data Analyst/Quality Assurance and Subject Matter Expert Team Lead

• Serve as a lead for the Quality Assurance / Subject Matter Expert team, managing 2 individuals
• Support multiple clients and client managers by creating business document specifications, quality analysis processes, and policy research supporting current analytics and recommend new analytics
• Serve as a subject matter expert on CPT, ICD-9-CM and HCPCS codes and coding guidelines
• Identify, analyze, and categorize potential fraudulent claims
• Research Medicare and State Medicaid policy and regulations to insure internal policies and procedures are accurate and up-to-date
• Keep current on federal, regional, and state issues, regulations and trends

Confidential

Position: Business Analyst

• Work closely with various Product Managers to provide assistance in meeting department and company goals in an Agile/Scrum environment
• Assist the Product Managers to determine requirements, specifications and workflows
• Analyze and document use case scenarios and works with other departments to incorporate functionality based on roadmap objectives for product line
• Analyze user specifications, document requirements, test and debug as required
• Exercise independent judgment to solve challenges inherent in application design and development
• Act as a resource for QA, Development, Support, Tech Writers and Training departments when questions arise concerning Company products
• Review new features and enhancements to determine if product specific, Meaningful Use and other requirements are met
• Analyze customer requirements and write detailed description of user needs and program functions using Adobe InDesign C5
• Analyze and ensure product enhancements are documented and implemented to meet or exceed CMS Centers for Medicare Medicaid Services Meaningful Use for EHR Electronic Health Record and HIT National Health Information Technology policies requirements
• Preparing Visio workflow diagrams, writing use case scenarios and acceptance criteria
• Provide content maintenance to metadata application using the following industry standard codes: Systemized Nomenclature of Medicine Clinical Terms SNOMED , Current Procedural Terminology CPT , International Classification of Diseases ICD-9-CM , etc.
• Serve as a lead in e-prescribing certification project with Surescripts. This effort includes: overall project management, quality assurance coordination, First Data Bank FDB data profiling, etc.

Confidential

Position: Information Technical Services Business Analyst II

• Understand, capture and document business issues and data challenges of client through effective individual client-specific communication
• Review and edit requirements, specifications, business processes and recommendations related to existing business processes
• Serve as lead for testing efforts for current projects. This includes writing test scripts and creating test documentation.
• Create and conduct client training and training documentation and materials
• Ensure issues are identified, tracked, reported and resolved in a timely manner
• Continually work with client to identify required changes and communicate needed changes to the development team
• Responsible for facilitation of client, vendor and project team meetings. Assist in enforcement of project deadlines and schedules.
• Communicate and apply Statement of Auditing Standards No. 70 SAS70 and other corporate defined standards to consistently deliver high quality services to clients
• Projects included: claims scanner installation and reconfiguration, web portal outsourcing, defining and gathering documentation on current business processes in preparation of migrating to a new claims processing system, implementing a care management automated plan model per the Center for Medicare Medicaid Services CMS federal regulatory requirements

Confidential

Position: Program Director to the Offices of the Attorney General and the Inspector General

• Serve as sole communication point person including planning, managing and controlling the day-to-day activities for the Offices of the Attorney General and the Inspector General OAG/OIG supported by multiple operational areas
• Establish operational objectives and work plans, and delegate assignments to various operational areas and owners as appropriate
• Work with State program peers to develop and enhance services that support program needs
• Provide contract management, training, product marketing and lead product support
• Provide leadership and focus in area of project management. Ensure projects meet contractual service requirements.
• Develop and subsequently implement new projects, policies and procedures for various department s to meet specific goals
• Formulate and implement procedures on operational processes ensure operations' effective achievement of objectives
• Prepare related reports and audit current procedures to monitor efficiency of projects
• Ensure business practices are performed in accordance with ACS policy, procedure and applicable federal, state and local laws and regulations
• Responsible for achieving measurable results on time and on budget

Confidential

Position: Principle Business Analyst

• Provide in-depth data analysis and health care analytics by accessing Vision21, the Texas Medicaid Data Warehouse, via Business Objects
• Analyze data issues in terms of available information, conceptualizing and defining problems, capturing and documenting metadata, gathering operational impact assessments, and formulating practical reporting and analytic solutions
• Provide expertise in the areas of claims processing and auditing, data warehousing, reporting applications and solutions, data extraction, ad hoc reporting, and encounter data analysis of requirements based on contractual agreements and data transmittal issues using national standard formats and general data analysis
• Work with operational business areas within the organization and Texas Health and Human Services Commission HHSC to map existing business processes to the MITA Medicaid Information Technology Architecture State Self Assessment business process model

Confidential

Position: Senior Principle System Analyst/Data Steward

• Ensure the needs of the business are met through thorough requirements gathering
• Accurately translate requirements into technical specifications
• Act as a liaison between the business owner and IT for a specific data source
• Analyze data issues surrounding both DB2 and UDB database build functions
• Develop and execute database validation and reconciliation procedures
• Use SQL to provide custom data related reports as needed
• Coordinate and maintain metadata for multiple data warehouses
• Develop, coordinate, execute data mapping and maintain multiple encounter data submissions for the Department of Human Services DHS Medicaid risk adjusted capitated payment consideration. This effort resulted in a 3 million dollar increase in revenue per year.
• Translate claims data into multiple standard media formats including EDI, ANSI X12, and NCPDP
• Serve as a mentor for new analysts/stewards
• Serve as lead for data integration project with Prime Therapeutics
• Provide data content and maintain two metadata applications. This includes documenting data lineage source-to-target .

Confidential

Position: Senior Benefit Analyst

• Program standard and non-standard benefits for new and renewing clients using File Aid a mainframe TSO tool
• Research, analyze and respond to internal referrals regarding claims, benefit coding and system processing issues
• Create detailed benefits recommendation proposals for potential clients
• Develop coding logic to implement retroactive legislative and amended benefits changes
• Create procedural edits to provide documentation on specific processing guidelines for standard and non-standard benefits including: commercial, administrative services only ASO and government contracts, etc.
• Create a new employee training manuals and materials for standard benefits analysis and coding
• Confidential
• Position: Accounts Receivable Credit Refund Examiner/Special Service Specialist
• Investigate and request the collection of monies for claims adjudicated in error
• Develop and implement an automated process to determine member coordination of benefits primacy based on TEFRA, ESRD, DEFRA, OBRA and COBRA laws
• Serve as a back-up customer service representative and technical specialist
• Research and resolve complex priority claims adjustment requests
• Direct support to the BCBSMN Medicare shop as well as Medicare shops nationwide

Confidential

Position: Senior Claims Adjustment Examiner

• Systematically administer contract benefits to ensure timely and accurate claims processing
• Research and document claims coding and system procedural problems
• Conduct analysis, investigation and resolution of specific centralized claims edits
• Provide personal claims support for multiple high dollar clients

Confidential

Position: Claims Initial Coder

• Responsible for claims coding for initial system entry
• Research and resolve claims edits
• Serve as a subject matter expert in national standard coding guidelines including ICD9, CPT, HCPCS, HCFA1500, UB92, etc.

Confidential

Position: Clerk

Clerically support multiple claims processing teams and their corresponding management