Verified Medicare drug and patient safety adherence measuresSkilled Nursing Facility analysis of PMPM, MLR, admits, re-admits, avg length of stay, risk scores, admits & days/1000 calculationsOther reporting including, but not limited to, member identification for care management programs, reinsurance claim identification, contract modeling, panel reports, utilization trends, DRGs/RUGs, pharmacy services, data extracts for vendors, standard claim utilization, PCP termination studies, etc.

Extracted, manipulated, analyzed and presented medical & pharmacy utilization, enrollment, provider and quality/disease management data for ad-hoc and standard reportingDeveloped an interactive, user friendly, hospital and ancillary facility contracting model used during negotiations to model the impact of various contract pricing scenariosRecipient of corporate "Best of the Best" award for creation of an $85M hospital contracting model which aided a successful negotiation with one of NJ's largest hospital systemsCreated macros for standard reporting in Access to increase efficiency and accuracyTrained new employees and reviewed work of other analysts to ensure accuracyExperience with PMPM cost comparisons, fee schedule analysis, reconciliations, recoveries, HEDIS specs for quality management mailings, loss ratios, etc.

Coordinated actions among departments to resolve and prevent claim/system set-up errorsTraveled to provider offices to recruit new network providers and educate existing network on claim payment policies, plan rules, electronic submissions and office site inspections

Monitored activities of three marketing representatives Traveled regularly to physician's offices to introduce our durable medical equipment, respiratory and pharmacy services

Resolved physician claim errors, educate provider offices on medical and payment policiesTraveled regularly to offices to discuss claims issues and policy changesAssisted physician offices in electronic claim submission

Proposed reimbursement options for CPT Evaluation and Management codesWorked with data analysts on report creation and recommendations

Formed database with demographic information for reporting and accuracy checksStudied DRG reimbursement to ensure profitability; presented findings to management