Data analysis working with large sets of claims data from multiple data sources. In this role I compile data stats for several different needs and produce reports in excel, tableau, access databases, whatever is needed.

• Responsible for claims oversight for TRICARE military health insurance plans. This involves leading testing initiatives and projects, reviewing TRICARE policy for process changes needed, tracking of claims data, internal claims monitoring for accuracy, and reporting data metrics.• Responsible for oversight of changes proposed and published by TRICARE into TRICARE policy by DHA (Defense Health Agency). This involves reviewing changes submitted from HGB Contracts to evaluate if any changes/updates would be needed for claims processing through our vendor to remain in compliance with DHA Government policy. This also involves tracking changes and maintaining cross functional collaboration among several different internal areas as well as our claims processing vendor.

Responsible for pharmacy claim/letter oversight for Transition claims for Medicare, Medicaid, and Dual Eligible plans. This involved leading testing initiatives, reviewing CMS guidance for process changes needed, tracking of claims data along with letter reconciliation, auditing (internal and external), and reporting data metrics. This also involved maintaining approvals for Transition letters being mailed to members and to physicians and maintaining policies and procedures regarding claims and letter logic processes.

Responsible for pharmacy claim/letter oversight for Transition claims for Medicare/Medicaid/and Dual Eligible plans. This involved testing claims logic changes, reviewing Transition logic process flows, tracking of claims data along with letter reconciliation, auditing (internal and external), and reporting data metrics. This also involved reviewing CMS guidance for possible process changes needed.

Responsible for pharmacy claim/letter oversight for Transition claims for Medicare plans. This involves testing claims logic changes, reviewing Transition logic process flows, tracking of claims data along with letter reconciliation, auditing (internal and external), and reporting data metrics. Responsible for vendor invoice reconciliation, authorization transfers, and exiting group pharmacy reports. This involves ensuring the correct amount is being billed to Humana through our vendors, loading authorizations for members new to Humana coming from another carrier, and gathering authorizations/deductible/claims data for exiting groups.

Responsible for loading of provider contracts into the Humana system for accurate billing/payments. This involved ensuring the provider was loaded in our system for the correct plans (HMO, PPO, etc.) and fee schedules.

Responsible for auditing Medicare Enrollment Specialist work of disenrollment, POA, enrollment, and pend areas. This required learning the processes these areas follow to adequately audit the work being performed. This also involved trending data to find any areas that may need to be retrained to the associates.

Responsible for resolving enrollment pends when there was an error with a member application. Also responsible for resolving errors being returned to Humana from CMS regarding enrollment files. When necessary a case would be compiled and filed to CMS to help clarify the member’s enrollment status.