Beatriz R. Email & Phone Number

Long Beach, California, US

• 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.

Long Beach, California, US

• (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.
• 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.
• 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.

Moorestown, NJ, US

• 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.
• 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.
• 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.

Frisco, Texas, US

• 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.
• Managed data sets (claim projects), reviewed & advised on how to handle processing and support special projects. Identified problems and solutions on multiple database systems.

Saint Louis, MO, US

• 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.

Saint Louis, MO, US

• 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.
• Reviewed claim reports to identify system or contractual issues or identified recovery opportunities.
• As a lead, trained coworkers towards SME abilities.

Saint Louis, MO, US

• 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.
• 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.

Fort Lauderdale, US

• 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.

US

• 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.
• 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, &.
• 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.

• 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.
• 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.

• 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.
• 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.

Data Analysis

Database Management

Laws & Ethics In Medicine

Dreamweaver Certificate, Web Page, Digital/Multimedia And Information Resources Design

Multimedia Production

High School Diploma, General Studies