• Performs data analysis and root cause analysis to identify and investigate service quality and compliance issues• Utilizes Lean principles, process mapping, various systems, and/or tools for the purpose of analyzing data and identifying performance gaps, and subsequently proposing process improvements• Performs periodic broad-quality reviews of departmental and compliance activities to determine the accuracy of established processes and procedures• Monitor and improve existing quality processes to streamline and ensure compliance with internal and external regulatory inquiry areas to generate relevant metrics and reports• Documents trends, gaps, waste, deficiencies, and barriers and recommends intervention strategies to positively affect business partner’s quality and improvement needs• Ensures that quality improvements are maintained and controlled• Create and deliver reports to reflect analysis and outcomes of defects, accuracy, and trends• Works with support areas to resolve customer problems, system issues, and exceptions resulting from internal or external audits• Recognizes and surfaces insidious and/or complex patterns of error trends, and incorrect transactions• Recognizes correlations between errors, identifies root causes, minimizes damages, and recommends corrective actions• Manage multiple initiatives with multiple customer priorities to meet targeted deadlines• Identifies training and coaching needs, may provide intense coaching at the team and department level when insidious and complex errors occur as needed

• Responsible for reviewing medical records, completing multiple audits, and special projects. • Collaboratively working with other departments.• Ensures risk adjustment coding is accurate and properly supported by clinical documentation within the health record. • Follows state and federal regulations as well as internal policies and guidelines while analyzing coding information and medical records. • Participate in provider education programs on coding compliance. • Determine daily priorities for an administrative workgroup and/or external vendors including coordinating work activities and monitoring progress towards schedules/goals, and often oversees work of others and/or is the primary administrative owner of a main process, program, product, or technology. • Reviewed member medical records for providers to verify and ensure appropriate and accurate diagnosis and procedural data in compliance with CMS and state specific guidelines.• Reviewed member charts, lab and consult reports for identifying documented diagnosis• Advised providers of missed opportunities• Developed relationships with providers and staff with consistent communication and training• Developed and maintained standard auditing policies and procedures• Educated providers in correct documentation and coding and provided educational material• Meets quarterly coding accuracy goals and meets monthly production goals.

• Investigated, reviewed, and provided clinical and/or coding expertise in the application of medical and reimbursement policies within the claim adjudication process through file review. • Performed clinical coverage review of post - service claims, which required interpretation of state and federal mandates, applicable benefit language, medical & reimbursement policies, coding requirements and consideration of relevant clinical information on claims with aberrant billing patterns.• Performed clinical coding review to ensure accuracy of medical coding and utilized clinical expertise and judgment to determine correct coding & billing.• Maintained and managed daily case review assignments, with a high emphasis on quality.• Provided clinical support and expertise to the other investigative and analytical areas.• Participated in provider / client / network meetings, which may include provider education through written communication.

• Maintain education regarding reimbursement and documentation requirements to remain compliant• Utilize claims and carrier expertise to approve payments and resolve any claims issues• Produce output exceeding internal production standards and meeting a 95% quality audit goal• Resolved aged credits to lead to a $7.1 million reduction of credits during 2017 fiscal year• Reviewed EOB's for various insurance carriers and completed necessary appeals needed for denials received• Analyze denied claims, resubmit claims, document claim statuses, request medical records, file appeals, redeterminations, etc.• Progressive experience in third-party, managed care, Medicare, Medicaid, Commercial payers, collections, UB04/1500billing procedures, cash applications, balancing, and reconciliation processes.• Implemented new ideas and procedures for efficient workflow

• Processed accounts receivable issues requiring expert knowledge of claims billing and review support• Analyzed Explanation of Benefit reporting to determine appropriate refund and adjustment amounts• Applied knowledge of CPT and ICD codes while reviewing documentation and claims information• On average, completed 75+ claims each day by ensuring claim files were properly documented and coded correctly.• Contacted 30-50/day insurance company representatives and patients to address account issues with timely and corrective measures.• Researched demographic and insurance information for completeness to correct any deficiencies and prevent delays in collection efforts.