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Reimbursement Specialis Resume

Pittsburgh, Pa

PROFESSIONAL OBJECTIVE:

My objective is to obtain a position that utilizes my extensive healthcare analytic and health insurance experience in an environment that provides challenging and meaningful work, as well as the opportunity to further expand myskills especially my statistical and technical aptitude.

SKILLS:
  • Proficiency in SQL, SAS, SPSS, VBA, and Microsoft Office.
  • Knowledge of traditional statistical methods including ANOVA, multiple linear regression, factor analysis, correlations, and MANOVA.
  • Functional understanding of HLM7 for use in analyzing hierarchical, time - series, and nested data.
  • Strong written, interpersonal, and oral communication skills.
  • Excellent analytical and problem-solving skills.
  • Strong organizational and time-management skills.
  • Experience engaging and motivating teams to accomplish goals related to performance improvement efforts.
  • Extensive knowledge of medical code sets including ICD-9, ICD-10, CPT, HCPCS, APR-DRGs, MS-DRGs, NDCs, and Revenue Codes.
  • Experience in evaluating, refining, and improving data collection, analysis, and reporting methodologies.
  • Highly skilled in using the internet to support research of data.
  • Demonstrated ability to work in a fast-paced environment.
  • Flexibility to adapt to changing conditions and requirements.
  • Demonstrated aptitude to work independently as well as in a team environment.
WORK EXPERIENCE:

Confidential, Pittsburgh, PA

Reimbursement Specialist

Responsibilities:

  • Core team member on Shared Savings implementation project responsible for validation of membership rosters and automation of reports utilizing Oracle SQL (Toad for Oracle), VBA (Visual Basic for Applications), MS Excel, and MS SharePoint, as well as creating and validating the internal Policy and Procedure Manuals and related documents.
  • Lead on special projects with primary focus being on government programs (Medicare and Medicaid - Pennsylvania Department of Public Welfare DPW ).
  • Produce detailed analytical reports and financial impact analyses using Oracle SQL, MS Excel, VBA, MS Access, MS Word, Cognos, and MS PowerPoint to measure provider performance in regard to quality and effectiveness of medical services and care, to identify utilization patterns, and to ensure market competitiveness.
  • Negotiate rate contracts for participating network providers for all insurance product lines, as well as negotiate rates for services provided by out-of-network providers.
  • Educate providers on reimbursement strategies by working directly with provider billing departments to resolve fee schedule and claim issues.
  • Identify issues involving documentation, coding, and billing to improve efficiency and effectiveness of practice management.
  • Design, analyze, and implement reimbursement models for risk/incentive contracting.
  • Analyze reimbursement fee schedules and reimbursement methodologies to ensure compliance with CMS and Pennsylvania DPW regulations.
  • Prepare requests for proposals (RFPs) for employer groups and network managers.
  • Present results of analyses to non-technical audiences both internal (including Senior Management) and external (including providers and hospital management).
  • Designed and administered job selection exam to prospective employees during the interview process for the Medicaid Reimbursement Specialist position.

Business Analyst II

Responsibilities:
  • Produced detailed analytical reports of clinical and financial data using Oracle SQL, SAS, MS Excel, VBA, MS Access, ArcGIS mapping application software, and MS PowerPoint to compare operating performance against regional and national benchmarks including HEDIS measures.
  • Identified trends in expenses, utilization, and medical quality, as well as identified potential fraud and abuse, performed cost/benefit analysis, and investigated variances to derive solutions to cost increases and quality issues.

Analyst I

Responsibilities:
  • Produced detailed financial and trend analyses using Oracle SQL, SQL Server, SAS, MS Access, and MS Excel.
  • Designed, created, and maintained computer programs using VBA to automate the renewal underwriting process.

Staff Underwriter

Responsibilities:
  • Underwrote health insurance for the Commercial (employer-sponsored) line of business for current and prospective groups.
  • Monitored regulatory changes and implemented updates to the risk assessment and rating process to ensure compliance with local, state, and federal regulations.

Confidential, Pittsburgh, PA
Test Center Administrator, Graduate Student Assistant

Responsibilities:
  • Complete check-in of examinees for computer-based testing.
  • Supervise test administration.
  • Maintain a working knowledge of policies, practices, and procedures.

Confidential, Morgantown, WV

Graduate Teaching Assistant

Responsibilities:
  • Developed and implemented lesson plans.
  • Prepared and structured lecture notes and handouts.
  • Delivered lectures and effectively managed classroom time.
  • Wrote quizzes and exams.
  • Graded homework, lab assignments, quizzes, and exams.
  • Held office hours and met with students one-on-one.

Lab Assistant for the Institute of Math Learning

Responsibilities:
  • Assisted students one-on-one with lab assignments.
  • Graded lab assignments.
  • Assisted the professors and instructors as needed.

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