• Analyzes and translates specific health care provider contract and pricing language to configure the Facets claims pricing system.• Develops and processes tests claims to ensure the accuracy of contract pricing.• Audits configuration builds across multiple types of providers and lines of business to ensure accuracy. Offers recommendations and coaching as necessary to enhance overall contract build quality.• Delivered comprehensive training sessions to new analysts. Tailoring training approaches to accommodate each analysts unique learning style.

• Overseeing audits for multiple lines of business, including Member Touchpoint Measures (MTM), Performance Guarantee (PG), Provider Data Audit (PDA), Federal Employee Program (FEP), and Par Plan. Conducting thorough reviews of claims, customer service, and EDI transactions to ensure and enhance overall quality.• Delivered comprehensive training sessions to both new and seasoned auditors across multiple lines of business. Tailoring training approaches to accommodate each auditor's unique learning style. • Conducted detailed post-training reviews of new auditors' work and consistently providing updates and recommendations to Internal Audit leadership.• Performed peer reviews to ensure the accuracy of audit findings. Offering recommendations and coaching as necessary to enhance overall audit quality.• Facilitated Calibration and Provider Data Audit (PDA) meetings, taking charge of agenda creation, introducing staff and subjects, and ensuring meetings adhere to schedules.• Conducted weekly and monthly validations of PG audits completed by team members. Ensuring the accuracy of internal and external reporting through meticulous validation processes.• Par Plan audit owner. Performing detailed claim payment reviews, analysis, and presenting results to external Blue’s plans.

• Successfully reviewed claims to ensure accurate denial, contributing to a $150k pre-denial audit project. Achieved significant savings of $1.2 million in interest from June 2017.• Demonstrated proficiency in reviewing live and correspondence, inpatient and outpatient, HMO, and PPO claims, showcasing versatility and comprehensive claims processing knowledge.• Reviewed submitted claims for accuracy, meticulously prepared necessary case documents for further medical review or necessity and processed complex high-dollar exception claims based on negotiated contracted rates, contributing to improved claims accuracy.• Consistently provided coaching to peers throughout the year, significantly enhancing processor and team quality, fostering a culture of continuous improvement.• Collaborated with leads and supervisors to implement updates to numerous DLPs (Data Loss Prevention policies), ensuring alignment with evolving business needs and contributing to process efficiency.• Functioned as an Interim Lead, acting as a liaison with multiple departments (FCR, CISD, Provider relations, etc.) to ensure timely and accurate processing of claims. • Demonstrated effective leadership in facilitating collaboration between departments for seamless claims processing.