• Investigating, evaluating, negotiating, and settling claims Applying knowledge of policies, procedures, laws, statutes, and insurance • Analyze complex information from different sources • Prepare and process claim reports Consult with specialists (i.e. physicians, medical resources) • Calculate benefits and payments • Negotiate settlements with claimants and attorneys • Support company attorneys & defend company in case of contestation • Conflict… Show more • Investigating, evaluating, negotiating, and settling claims Applying knowledge of policies, procedures, laws, statutes, and insurance • Analyze complex information from different sources • Prepare and process claim reports Consult with specialists (i.e. physicians, medical resources) • Calculate benefits and payments • Negotiate settlements with claimants and attorneys • Support company attorneys & defend company in case of contestation • Conflict resolutions and/or mediations • Examine police reports, videos from surveillance cameras or audio when applicable • Contacting customers via telephone, written correspondence and/or various electronic media • Effectively managing work through task driven queues while multi-tasking in a fast-paced call center environment • Supporting customers through personalized, caring, and simple interactions Show less

• Manage and oversee a staff of 8 employees that consist of Sr. Research Analyst, Clinical Liaison, Clinical Coders, Implementation analyst• Coordinate and provide assistance to the state stakeholders of the Medical Policy Support Annual and Quarterly reviews of the International Classification of Disease (ICD) and HealthCare Common Procedure Coding System (HCPCS) process • Oversee the coordination of the MPS Research Business Service Requests that… Show more • Manage and oversee a staff of 8 employees that consist of Sr. Research Analyst, Clinical Liaison, Clinical Coders, Implementation analyst• Coordinate and provide assistance to the state stakeholders of the Medical Policy Support Annual and Quarterly reviews of the International Classification of Disease (ICD) and HealthCare Common Procedure Coding System (HCPCS) process • Oversee the coordination of the MPS Research Business Service Requests that are submitted from various internal areas that consist of researching provider inquiries and system updates• Monitor and respond to Medicaid Contracts Administration Tracking System (MCATS) and State Action Request (SAR)• Monitor the Legislative inquiries and impact surveys to determine medical policy impacts• Monitor technology system updates conducted through Demand Management Meetings that have medical policy impacts. • Ensure the monthly Medicaid and CSHCN Service Program medical policy implementation timelines were met• Facilitate or attend the state stakeholders Benefit Assessment Meetings (BAM) for policy development• Facilitate the bi-weekly internal medical policy implementation meetings• Serve as a liaison between operational staff, technical team, and State agencies• Attend and provide medical policy updates during the bi-weekly state stakeholder Medical Policy Check-in meetings • Attend internal/external operational meetings to include state stakeholders for various system enhancements, Legislative, State Medical Benefits Meetings• Experience managing complex, cross-functional projects and strategic planning• Exceptional communication skills• Research data, analyze and complete research/review of various projects requested by leadership• Created and executed the Project and Portfolio Management (PPM) system enhancement to support the medical policy flow process Show less

• Preform monthly QA of the Medicaid/CSHCN medical policy implementations• Monitor, research data and respond to Medicaid Contracts Administration Tracking System (MCATS) and State Action Request (SAR)• Maintain Medical Policy Implementation and SAR spreadsheets• Track and research related medical policy, Reference Data Maintenance (RDM), Document Research Team (DRT), pricing unit and application services Business Service Request (BSRs) with medical policy impact• Provides… Show more • Preform monthly QA of the Medicaid/CSHCN medical policy implementations• Monitor, research data and respond to Medicaid Contracts Administration Tracking System (MCATS) and State Action Request (SAR)• Maintain Medical Policy Implementation and SAR spreadsheets• Track and research related medical policy, Reference Data Maintenance (RDM), Document Research Team (DRT), pricing unit and application services Business Service Request (BSRs) with medical policy impact• Provides expertise in the areas of operational requirements of policy deployment, assist in development • Served as a liaison between operational staff, technical team and State agencies• Attend bi-weekly Operations Implementation meeting• Research data, analyze and complete various projects Show less

• Liaison to research referrals and complaints received from the State and Legislative offices• Respond to each request with concise detailed documentation summarizing the research findings. • Monitor each case which is date and time sensitive and requires strong organization skills to manage the number of requests.• Collaborate with other impacted areas to resolve issues

• Preform monthly QA of the Medicaid/CSHCN medical policy implementations• Monitor, research and respond to Medicaid Contracts Administration Tracking System (MCATS) and State Action Request (SAR)• Collaborate with the medical policy nurse analyst on incoming SARs• Maintain Medical Policy Implementation and SAR spreadsheets• Provided monthly Medicaid/CSHCN policy implementation reporting to HHSC Benefit Implementation Process (BIP) Project Manager.• Track and research… Show more • Preform monthly QA of the Medicaid/CSHCN medical policy implementations• Monitor, research and respond to Medicaid Contracts Administration Tracking System (MCATS) and State Action Request (SAR)• Collaborate with the medical policy nurse analyst on incoming SARs• Maintain Medical Policy Implementation and SAR spreadsheets• Provided monthly Medicaid/CSHCN policy implementation reporting to HHSC Benefit Implementation Process (BIP) Project Manager.• Track and research related medical policy pre-analysis, RFT, DRT, fiscal/pricing unit and application services Business Service Request (BSRs) with medical policy impact• Served as a liaison between operational staff, technical team and State agencies• Perform/present Medicaid/CSHCN policy reporting at the bi-weekly Benefits Management Workgroup (BMW) Executive meetings• Facilitate bi-weekly Operations Implementation meeting• Attended bi-weekly BIP and CSHCN meetings• Research, analyze and complete various projects Show less

• Perform analysis to establishment of policy requirements, subject matter expert, development of procedures, and other related analytical and technical duties• Analyzes user needs to determine functional and cross-functional requirements• Attends meetings as a subject matter expert regarding policy implementation• Provides expertise in the areas of operational requirements of policy deployment, assist in development • Interfaces with other departments in representing the… Show more • Perform analysis to establishment of policy requirements, subject matter expert, development of procedures, and other related analytical and technical duties• Analyzes user needs to determine functional and cross-functional requirements• Attends meetings as a subject matter expert regarding policy implementation• Provides expertise in the areas of operational requirements of policy deployment, assist in development • Interfaces with other departments in representing the customer in the course of conducting interoperability and supportability procedures• Operates independently and react rapidly in a complex organizational environment with daily departments interchange and multi-faced tasking while providing insights and independent thought and advice on interoperability areas Show less