Edwin Bowman Email & Phone Number

United States

Perform benefits configuration implementation for Commercial LOBs into QNXT 5.8 for claims and provider relations departments.

Irving, Tx

- Implement and maintain all updates to the fee schedules for Medicare, Medicaid, and TriCare in the MediTrac system.- Accurately load new Commercial plan and benefit structures into the applicable system. - Build and maintain fee schedules and accompanying contracts to ensure correct pricing methodology.- Update and implement the conversion of the ICD-9 codes to ICD-10 to ensure proper diagnosis codes are utilized.- Analyze claims to ensure they are processing correctly according to the fee schedules loaded.-Perform system testing of fee schedules prior to implementation to determine accuracy and proper loading.-Operate interdepartmentally to maintain proper functioning of claims loading and resolution of any disputes or complaints. - Create explanation codes when required to rectify and/or communicate claim activity.- Export Medicaid, Medicare, and TriCare fee schedules from TMHP annually to make updates/changes in the system if needed.

Dallas/Fort Worth Area

- Implemented and maintained all updates to the fee schedules for Medicare and Medicaid.- Reviewed claim run cycles nightly for accuracy and error identification. - Gathered business requirements and translated them into automated solutions. - Provided feedback to the claims department on a daily basis of edits, denials, updates, or any other activities involving claims.- Built operational reports for claims to identify and/or rectify any claims issues. - Audited loaded fee schedules, examined/repriced claims, and performed UAT tested for upgraded systems. - Loaded and tested eligibility files, contracts, Medicaid and Medicaid fee schedules, HIPAA compliance codes, provider files, and FTP data file transfers. - Processed mailbox containing system issues related to claims, fee schedules, and contracts.- Performed UAT for system upgrades and new implementations to ensure proper configuration.

Dallas/Fort Worth Area

- Built Medicaid benefits according to health plan structure and design.- Audited loaded fee schedules, examined/repriced claims, and performed UAT tested for upgraded systems. - Loaded EDI files, contracts, Medicaid fee schedules, HIPAA compliance codes, eligibility/provider files, and FTP data file transfers. - Tested Trizetto system for HCPCS and CPT procedure code for accurate claims payments. - Built operational reports for claims to identify and/or rectify any claims issues. - Maintained provider contract data for accuracy and updated as needed.