• Responsible for accurate and timely implementation and maintenance of critical information on claims databases.• Analyze and interpret data to determine appropriate configuration changes.• Accurately interprets specific state and/or federal benefits, contracts as well as additional business requirements and converting these terms to configuration parameters.• Handles coding, updating, and maintaining benefit plans, provider contracts, fee schedules, and various system tables through the user interface.• Create test plans, point of concepts, and migrations and perform UAT testing of configuration and migration.

(1) Inventory Management Improvement - Responsible for reviewing the claims inventory report for any stranded claims with a paid status. Inform leadership of my findings as this would mean that the SLA’s were not met for the corresponding department.(2) MHI Audit Tool / SLA Compliance- Trend analysis of all audits performed and recorded in the MHI Audit Tool database. Monitor SLAs with specific formulas and notify leadership of each department of my findings.• Accomplishments: Educated Claims Supervisors and Auditors of the criteria needed in the MHI Audit Tool to ensure that the team is meeting the SLAs required.(3) Data Integrity Team - Assist with monitoring Iserve tickets of claims report requests for multiple states and lines of business and pull reports via TOAD using prewritten queries templates.• Accomplishments: Reduced Iserve Ticket backlog of 6 months, actively maintaining SLAs in new ticketing process & created & update a weekly report for the Triage team. I have discovered discrepancies that will improve inventory once addressed.

Responsible for analytical data needs and manage complex data requests & reports such as: • Analyze data collection, validation, and outcome measurement. Root cause, research and recommendations are given to management per business need. This includes provider network data, configuration, and claims data for CMS reporting. Trend analysis for various functional areas such as authorization loading errors, KPI data for multi clients, review and analyze trends for problematic data results due to SQL logic and system limitations. Perform UAT (User Acceptance Testing) of authorization interfaces.• Generate reports using pre-written SQL queries with direct links to core databases. (Minor ability to manipulate query as needed). I work closely with the SQL programmer and discuss logic as needed and I have strong intermediate Excel skills.• Investigate and resolve data issues and communicate risks/issues with management regularly. Participate in multi meetings and service as an SME and give recommendations. • Accomplishments: Implementation of UDF fields to be compliant with CMS reporting, E&Y audit data mapping, implement authorization error process using SharePoint, created, and maintained business requirement documents for our department, & introduced workaround solutions for CMS data for our clients.

• Served as a liaison between departmental team business partners, end users, I.T., Claims and Clinical departments. Responded to ad hoc requests for support, reports, and analysis.• Query data warehouse and internal databases, prepare user friendly reports. Gathered data, root cause analysis, validation and communicated recommendations. UAT (User Acceptance Testing) of new functions or changes in processes.• Managed data sets (claim projects), reviewed & advised on how to handle processing and support special projects. Identified problems and solutions on multiple database systems.

• Served as a liaison between providers, the health plan and corporate. • Conducted monthly face to face meetings with the providers documenting discussions, issues, and action items. Researched claims issues & routed to the appropriate department for resolution.• Performed training sessions, orientation, & educated providers regarding policies and procedures related to referrals, claims submission, web portal education. • Initiated entry or change of provider data in the database and oversee testing and completion of change request.

• SME for the plan, internal & external partners to effectively identify & resolve claim issues.• Analyzed trends in claims processing issues & recommended work process solutions such as system changes, authorization issues, eligibility, & systematic issues/trends that may cause over /underpayments. Communicated with internal departments & management of trends and concerns.• Reviewed claim reports to identify system or contractual issues or identified recovery opportunities.• As a lead, trained coworkers towards SME abilities.

• Analyzed trends in claims processing issues & recommended work process solutions such as system changes, authorization issues, eligibility, & systematic issues/trends that may cause over /underpayments. Communicated with internal departments & management of trends and concerns.• Quality audit the check run data for accuracy and identified issues and resolved to its completion.• Reviewed multiple claims reports to identify system or contractual issues and or recovery opportunities.

• Contract physicians for the Best Choice Plus Plan & assist with credentialing & negotiated ancillary contracts. • Managed as a liaison the PHO Network. PHO Network contained 28 health plans with lines of business such as Commercial, Medicare, Medicaid, Healthy Kids, Worker's Compensation & International Plans. • Established and maintained ongoing relationships with network physicians.• Handled all escalated issues pertaining to system rate configuration, research contractual issues & interpreted contracts for reimbursement and claims issues.• Daily maintenance of the Access database with all demographic changes, additions, clean up, and reporting functions. Various document preparations: Applications, contracts, & files.

• Installed & administered assigned contracts, structure & billing set up, database loading using UNO web-based application. Responsible for overall provider contract & amendment loading and processing using various databases/platforms, audit contract loads for adherence to quality measures and reporting standards.• Network account manager support with contract maintenance functions including but not limited to initiate contract request according to current market strategy, review demographic & tax id changes, claim issues, & Medicare panel audits.• Provider Relations phone support for the physician contracts department, including but not limited to investigate claim issues due to group record discrepancies, NHP contract loading issues, perform panel audits, reach out to internal business partners, & update MIC (web-based application) issues.

• Researched Medicare & pharmaceutical benefits from all competitors in the state of Florida & prepared analysis and trends. • Reviewed and project managed departmental work plans for the CMS Call Letter filings for Medicare & Medicaid benefits. Created templates & compliance documents with CMS model instructions for Annual Notice of Change, Evidence of Coverage, Summary of Benefits, & Provider Directories. (19 plans for the state of Florida)• Assisted the Implementation Manager & VP of Product & Development with planning departmental meetings, presentations, and training. Draft and prepare training documents, crosswalks, and newsletters for internal departments.

• Apply claim guidelines and regulations pertaining to capitation, pre-existing conditions, member effective dates, co-pays, deductibles, coordination of benefits, provider relation issues, referrals, authorizations, and benefits usage. Review code review edits, duplicates and made necessary adjustments on previous denied claims as required.• Responsible for escalated claim issues, in charge of high claims profile accounts for claims processing & train team members for correct contractual reimbursement.• Identified system or benefit configuration issues and communicated with the appropriate department.

Processed commercial professional claims.