Helena Lopez Email & Phone Number

Chesterfield, Mo, Us

Philadelphia, Pa, Us

• The SIU Data Team supports several lines of business by providing data requests, data mining, initiating and tracking financial progress, and providing regulatory and audit reporting.• Data Mining SME tasks consist of creating and running algorithms, using advanced filters and formulas in Microsoft Excel to find outliers in data, creating data mining scenarios, reviewing providers for potential FWA, ad-hoc data mining requests from investigations team, and presenting those results. • Restructured the financial process of AmeriHealth’s SIU by auditing three years of SIU recoveries and corrected all discrepancies. Created a weekly tracking system to ensure accuracy with all financial reporting. Providing bi-weekly financial updates to senior management. Created monthly presentations for executive level leadership to review. • Led a team of three data analysts by delegating and advising on workflow, training, and troubleshooting.• Led a team of three intake specialists and a screening investigator by advising on case generation, training, and correcting internal processes to eliminate the current backlog of tips. • Maintaining, updating, and improving monthly and quarterly regulatory reporting. Presenting reporting results to management and clients. • Maintaining a relationship with vendor, Cotiviti, implementing changes to the product, adding new plans, training of the product, and reviewing monthly data load.• Developed FRDs and implemented new plans and interpreting contractual needs of client and implementing any changes based on contract. • Maintain collaborative and professional relationships within the department and company by always being available for questions and concerns.

Philadelphia, Pa, Us

• Work independently within the Special Investigations Unit in Program Integrity which the primary focus is on data mining. • Data analysis is created within scenarios in case management system and researched monthly or quarterly depending on the specific allegation focus. • Case referrals are developed and assigned to investigator. • Data mining reporting is conducted for all lines of business to help investigators and management in conducting data mining and view any outliers. • Strong ability to work efficiently without leadership present by exhibiting dependability, timeliness, and constructive behavior under stressful situations.

Us

• Catamaran was bought out by OptumRx.• Led and mentored a team of pharmacy analysts and pharmacy auditors. • Extensively research potential fraud, waste, abuse through data mining, ownership links, schemes found during interviews, social media, etc. • Lead onsite projects in HEAT zones consisting of surprise pharmacy visits by conducting various interviews and gathering documentation. The results of these audits have resulted in financial recovery, disciplinary action, and/or termination from the network.

Schaumburg, Illinois, Us

• Special investigations were conducted by performing prescription and invoice reviews, along with member and doctor verifications. • Investigations focus on the trends and schemes found during data mining.• Monitoring pharmacy activity within the assigned HEAT zone. • Work independently to find trends of FWA by data mining, create cases, and complete review of claim data and hard copies. • Onsite audits on pharmacies were conducted quarterly.

Kansas City, Mo, Us

• Monitor 60k pharmacies FWA by conducting desktop and onsite audits nationally to ensure compliance within Argus Network.• Lead project to automate pharmacy audit process by assisting in developing an application that detects discrepant claims and pharmacy outlier trends.• Pharmacy Audit Liaison SME with client insurance plans to provide updates on audits and reporting.• Research updates on CMS, federal, and state regulations to ensure compliance. • Created training process and policies and procedures to ensure the department meets performance goals.

Kansas City, Mo, Us

Reviewed prior authorization for specialty and high dollar medications. Educated doctors on step therapy methods and other insurance benefits.