David Chavez Email & Phone Number

Escondido, Ca, Us

San Diego, California

• Leads audits related to high profile and complex health plans.• Facilitates and leads internal and external meetings acting as owner of information. Including the creation and distribution of meeting agendas, kicking off the discussion with a high level overview and purpose of the meeting, introductions, and closing discussion with action items. Includes facilitation of any internal preparation meetings and coordination of details to internal stakeholders prior to meeting to provide… Show more • Leads audits related to high profile and complex health plans.• Facilitates and leads internal and external meetings acting as owner of information. Including the creation and distribution of meeting agendas, kicking off the discussion with a high level overview and purpose of the meeting, introductions, and closing discussion with action items. Includes facilitation of any internal preparation meetings and coordination of details to internal stakeholders prior to meeting to provide enough information in preparation for their role in audit discussions.• Proactively engages internal business owners and subject matter experts to effectively manage internal and external customer expectations.• Actively participates in collaborative team environment to educate, coordinate activities and resolve unique problems with recommended course of action to internal stakeholders.• Uses best efforts to acknowledge receipt of emails from clients within 24 hours of receipt.• Maintains timely and accurate documentation of client interactions, activities, processes and issue resolution; ensures meeting minutes and action items are prepared and documented within two days of a client meeting.• Communicates with Sr. Manager Delegation Support and Sr. Director, CTS on high level issues to ensure appropriate response and resolution.• Establishes and maintains positive professional relationships with internal and external customers.• Maintains confidentiality of all reports, files, schedules, databases and documents as well as all member, provider and proprietary information.• Communicates unique aspects of client delegation activities at various meetings with internal and external customers to support delegated functions.• Participates in activities related to internal and external process improvements.• Supports functions of the Compliance Office with completion of compliance work plan and risk assessment goals and action items. Show less

San Diego

• Understanding of Prescription Drug Event (PDE) edit resolution, roles and responsibilities across the organization. Analyzes and reconciles PDE entries rejected by CMS, including rejections related to eligibility and PDE calculations. Analyzes trends in rejected records and clearly conveys issues to clients along with recommendations for resolution.• Manages PDE file generation process from end to end. Including cycle generation, executing PDE load and extract programs, file quality… Show more • Understanding of Prescription Drug Event (PDE) edit resolution, roles and responsibilities across the organization. Analyzes and reconciles PDE entries rejected by CMS, including rejections related to eligibility and PDE calculations. Analyzes trends in rejected records and clearly conveys issues to clients along with recommendations for resolution.• Manages PDE file generation process from end to end. Including cycle generation, executing PDE load and extract programs, file quality control, file submission to CMS or clients. Executes the retrieval and processing of CMS response files, providing detailed analysis of file results. Provides concise feedback to clients on file outcomes and resolution.• Demonstrates knowledge of PDE reporting requirements including comprehensive understanding of the PDE and Medicare DDPS response file layout.• Maintains current understanding of assigned client’s Medicare Part D benefit plans in order to analyze the accuracy of PDE records prior to submission.• Establishes positive working relationships with internal and external clients by providing sustainable, measurable, accurate, reliable and timely execution of PDE data tasks. Delivers solution-oriented problem solving techniques.• Utilizes multiple company databases to obtain record and analyze complex claim information.• Participates in interdepartmental meetings and client conference calls as the subject matter expert regarding Medicare Part D PDE data.• Demonstrated ability to prioritize urgent issues effectively. Outstanding numeric, verbal, written, logic and analytical skills. Knowledge of healthcare operating systems. Detail oriented with a high degree of accuracy & follow through. Self –starter able to work independently & as a part of a team. • Define problems, collect data, establish facts and draw valid conclusions. Interpret an extensive variety of technical instructions.• Calculate figures and amounts such as discounts, interest and percentages. Show less

Greater San Diego Area

• Technical analyst within testing and validation and other internal departments including benefits configuration, pharmacy network configuration, client implementation and account management.• Responsible for the development of testing strategies, developing specifications of business requirements and collaborative involvement with other departments to enhance core testing infrastructure to ensure flawless benefit implementations.• Acquired a thorough understanding of system logic for… Show more • Technical analyst within testing and validation and other internal departments including benefits configuration, pharmacy network configuration, client implementation and account management.• Responsible for the development of testing strategies, developing specifications of business requirements and collaborative involvement with other departments to enhance core testing infrastructure to ensure flawless benefit implementations.• Acquired a thorough understanding of system logic for claims adjudication, system constraints, conflicting benefit logic configurations, design to ensure design satisfies intended solution.• Ensures consistent customer satisfaction by proactively assuming a leadership role through consultation and collaboration with external clients, client team members, to ensure that business requirements for benefit configuration requests are clearly understood, documented, developed, communicated, tested and delivered flawlessly.• Day to day responsibilities include research, quality assurance, analysis and test development specifications.• Reviews results of testing and validation processes to support completion of end-to-end testing and validation plans to ensure thorough and complete testing is conducted to validate new benefit plan configurations.• Work directly with account managers, implementation managers, benefit configuration analyst and BA team members to verify, facilitate and implement client benefits successfully.• Recognize unique or problematic situations and formulate solutions in conjunction with client benefit analyst, implementation and account managers.• Utilizes project planning, prioritization, and organizational skills to ensure timely deliverables, high levels of quality and efficient use of resources to achieve claims adjudication accuracy.• Promptly responds to service failures, resolves issues and escalates concerns as appropriate.• Promotes continuous improvement by ensuring adherence to quality principles. Show less

Greater San Diego Area

• Develop and prepare system specifications for assigned system applications for implementation by IT Program developers.• Gather and translate general business requirements.• Serve as a liaison between the Business Owners and Development team for existing, new programs, applications, functions, and user requirements.• Perform research to gather necessary information and prepares analysis of data.• Work directly with manager and BA team members to implement system… Show more • Develop and prepare system specifications for assigned system applications for implementation by IT Program developers.• Gather and translate general business requirements.• Serve as a liaison between the Business Owners and Development team for existing, new programs, applications, functions, and user requirements.• Perform research to gather necessary information and prepares analysis of data.• Work directly with manager and BA team members to implement system changes.• Recognize unique or problematic situations and formulate solutions in conjunction with Business Owners, Managers and BA team members.• Assists in creating documentation and user training guides on system applications and changes.• Maintains working knowledge in areas of assigned responsibility for the use in the development of system enhancements and reporting requirements.• Responsible for the preparation and deliver of regular timely reports for other departments.• Coordinate appointments, facilitate, attend, prepare meeting materials and notate minutes for weekly meetings to coordinate activities and projects with Business Owners, Managers, Developers and BA team members.• Represent BA team in weekly Upper Management meetings for client setup and contract development specifications to provide information on system limitations, requirements and status updates.• Responds to calls, correspondence and email as necessary.• Maintains follow up to ensure timely and accurate completion of assignments. Show less

Greater San Diego Area

• Monitor, verify and update information on submitted claims.• Perform quality review by comparing claim form to claim information entered into the claims payment system.• Visually review claims correspondence including explanation of benefits (EOB), clinical treatment forms (CTF) and referrals to verify appropriate data to be entered for coordination of benefits. Make necessary modifications or corrections to insured's claim and records.• Visually review charges, determine if claim… Show more • Monitor, verify and update information on submitted claims.• Perform quality review by comparing claim form to claim information entered into the claims payment system.• Visually review claims correspondence including explanation of benefits (EOB), clinical treatment forms (CTF) and referrals to verify appropriate data to be entered for coordination of benefits. Make necessary modifications or corrections to insured's claim and records.• Visually review charges, determine if claim is payable or if additional information is needed, access the computer system and utilize denial codes and/or type denial letters/correspondence, within established department guidelines and standards.• Assisted other claims teams and departments as needed. Show less

Greater San Diego Area

• Enter data from Claim Forms into the claims processing system • Responsible for the accurate review, input and adjudication of claims in accordance with regulations, departmental policies, procedures, and contractual obligations of the organization. • Provides assistance to supervisors and examiners. Assists in training of new claims personnel by providing error feedback.

Greater San Diego Area

• Responsible for completing corporate processing requests, fulfillment requests, and package handling services. • Performs daily mail assembly and fulfillment activities as assigned. Handles shipments and deliveries, assists with claims, returned mail, and inter office deliveries. Assists with inventory cycle counts and kit prep. • Responsible for quality control in all aspects of assembly and mail prep. Prepares Fulfillment requests for shipping or mailing following quality control… Show more • Responsible for completing corporate processing requests, fulfillment requests, and package handling services. • Performs daily mail assembly and fulfillment activities as assigned. Handles shipments and deliveries, assists with claims, returned mail, and inter office deliveries. Assists with inventory cycle counts and kit prep. • Responsible for quality control in all aspects of assembly and mail prep. Prepares Fulfillment requests for shipping or mailing following quality control processes. Assists shipping and receiving duties. • Assists with inventory and weekly cycle counts. • Provides direct support as needed to assure daily corporate requests are processed timely. Show less

Greater San Diego Area

• Processed, routed and confirmed daily shipment of data to account holders. • Filed received data in central library in an accurate serialized manner. • Accurately converted alpha/numeric data into the company’s proprietary software program to generate a schedule of account holders shipping and receivables. • Audited data storage received and reported discrepancies to management. • Provided customer service on follow-up services, complaints, and/or to assist in the preparation… Show more • Processed, routed and confirmed daily shipment of data to account holders. • Filed received data in central library in an accurate serialized manner. • Accurately converted alpha/numeric data into the company’s proprietary software program to generate a schedule of account holders shipping and receivables. • Audited data storage received and reported discrepancies to management. • Provided customer service on follow-up services, complaints, and/or to assist in the preparation of a disaster recovery plan. • Worked with account holders to resolve system/application issues in an expeditious manner. Provided 24-hour operational support and on-call emergency coverage. Show less

Project Management Certification Program (Pmcp), Project Management

B.S. Information Technology, Business Systems Analysis

Transfer Studies

Activities and Societies: Associated Student Government