Configure claims pricing system per Medicaid, Medicare, Exchange, and Commercial requirements.

§ Manage and define system configuration requirements.   Responsibility for requirements, definition, document, design, testing, training and implementation support using appropriate templates or analysis tool§ Develop and utilize reports to analyze and stratify data in order to address gaps and provide answers to issues identified within the department or by other departments§ Identify, manage and document the status of open issues, configuration design, and final resolution within change management system§ Review and interpret regulatory items, timely delivery of required updates§ Development of standard code set and reimbursement design templates§ Plan and implement new software releases including testing and training§ Participate in meetings with business owners, users and IT to achieve solutions that meet the requirements and expectation of CareSource Lead configuration initiatives in payment policy meetings and present to committees§ Coordinate annual benefit changes with internal resources§ Provide analysis of efficiencies related to system enhancement and automation. Review, analyze, and document effectiveness and efficiency of existing systems and develop strategies for improving or further leveraging systems§ Manage the reimbursement review.   Identify and design appropriate changes. Lead the development and execution of test plans and scenarios for all reimbursement designs for core business system and related processes§ Audit configuration to ensure accuracy and internal controls to minimize fraud and abuse and overpayment related issues§ Anticipate and identify customer needs and match products and services to facilitate the fulfillment of those needs§ Ensure system processes and documents exist as basis for system logic§ Manage resources and communications to facilitate work completion§ Mentor the use of tools to define requirements

•Responsible for the correct set-up and functioning of the third-party clinical editing system – ClaimsXten, the related provider interface - Clear Claims Connection, and the application that houses the clinical editing rules – Content Manager•Worked with vendors and other departments to deploy the correct ClaimsXten and Clear Claims Connection files to non-production Facets environments. I validated the data transfer and then deployed the files to the Facets production environment. •Created and ran queries in TOAD for Oracle to obtain data for problem solving and enhancement of claims and clinical editing systems.•Created testing scenarios and ran test claims to ensure correct system configuration and to validate fixes, enhancements and upgrades.•Performed post-implementation quality assurance, troubleshooting and issue resolution.•Responded to customer inquiries regarding system functionality, modification and status of issue resolution.•Reviewed and analyzed sustainment issues associated with claims and clinical editing systems and processes. Developed scripts that moved or updated data to replicate online functionality.System Experience – Facets, ClaimsXten, Clear Claims Connection, Optum CES, FEPDirect, Remedy, Rally, TOAD/SQLVendor Experience – Change Healthcare (McKesson), Cognizant (Trizetto), Optum

•Utilized specialized medical classification software to assign procedure and diagnosis codes for DRG determinations and performed code validation searches for revenue code/CPT code mismatch and unbundling.•Reviewed medical records to determine appropriate billing compliance with company administrative, medical, pharmacy, and reimbursement policies. •Created Nurse Auditor DRG review documents including CC, MCC, and clinical indicators and created user manuals and desk references for other Audits.•Created “DRG outlier calculator” in Excel to ensure nurse auditors, supervisors, managers, and Appeals department maintained accurate audit denials and total allowed amounts when corresponding with providers.•Researched provider contracts and created abstracts pertaining to hospital billing and claims submission for use in line-by-line, DRG, Hospital Acquired Condition, Place of Service, and Medical Necessity audits.System Experience – Facets, FEP Direct, RADARProgram Experience – Encoder Pro, WebStrat, Availity, Outlook, Sharepoint, OneNote, Excel, Word

•Created pricing using CMS, Noridian, Ingenix, TRG, pharmacy and contract reimbursement methodologies. •Consulted with Contracting, Pharmacy and Production Support staff to implement innovative provider pricing agreements including RBRVS, DRG, RUG, OPPS, PPS and APC pricing.•Researched pricing methodologies and made recommendations to Contracting and Actuarial staff regarding system capabilities in both legacy and NetworX Pricer systems.•Investigated pricing errors and recommend changes in procedures, contract language, or system limitations to increase the auto-adjudication rate.•Developed and posted pricing information for use by other departments to correctly price claims. •Accountable for initial departmental SAS70 audits - coordinated test scenarios, researched andcompiled test documentation. System Experience – Facets, NetworX Pricer, PIMS, RADARProgram Experience – WebStrat, Outlook, PowerPoint, Access, Excel, Word

Audited high-dollar claims for proper pricing and payment of benefits: •Researched source documents including provider agreements, member contracts, and CMS guidelines to ensure accuracy in data entry, member eligibility, plan/product information, billing, provider information, pricing, and benefits application. •Applied hospital contract pricing for catastrophic, expired, transfer, inliers, outliers, and excluded DRGs as well as pricing for pharmacy, mental, chemical dependency, and skilled nursing services.•Performed targeted audits to identify provider billing errors, system and set-up errors, and documentation inaccuracies. Program Experience – Outlook, Excel

• Delivered training in the Facets Suite of Systems in over 30 applications across the 4 Regence states.• Prepared and delivered specialized training to Oregon customers.•Assisted with live production issues during go-live system implementation. •Verified end-to-end processes with Business Systems Analysts and super users. System Experience – Facets, RIQ, RADAR, Client Letter,Program Experience – PowerPoint, Outlook, Excel, Word

Conducted one- and two-day public training seminars across the United States in the following topics:Interviewing PeopleTotal Time Management – How to Organize Your LifeHow to Deal with Difficult and Demanding CustomersHow To Design Training So Anyone Can Present ItHuman Resources and the LawEssentials of Human Resources