Responsibilities include determining Benefit intent, through evaluating administrative cost, medical expense, member satisfaction and regulatory requirements. Triaging work to appropriate stake holders. Maintaining a fundamental understanding of health plan products to assure Martin's Point is accurately administering benefits.

Responsibilities include proactively providing system configuration and workflow intent. Triaging work to appropriate stake holders. Maintaining a fundamental understanding of health plan products to assure Martin's Point is accurately administering benefits.

My primary function is the creation and maintenance of policy and procedures for the Health Plan. My secondary functions include:• Process Improvement: Developed and created the LINK excel database. A resource HUB that consolidates, workflows, calculation (DRG, OPPS, etc.), tools and tips into one simple efficient location (LINK has reduced process time up to 10 minutes per claim on some claim edits).• Benefit Department: Determine how and if a benefit can be administered per Medicare/Tricare Regulation, Company Policy, Administration Cost, and actual cost. Communicating policy changes to the appropriate internal customers. Determine prior authorization requirements for new procedure codes.• Tricare Records Manager: Responsible to assure federal regulations are met and to maintain/create policy as created.

Applied claim payment based upon Medicare and Tricare regulations and guidelines. Payment methodologies including but not limited to: OPPS, critical access, fhqc, standard fee schedules. Applied appropriate cost shares and payment utilizing QNXT claim system. I helped build the USFHP benefits in the system and routinely provided system corrections for implementation.

Created and designed the Connections excel database. This program consolidated the benefit information of 266 unique Jointly Adminstered Accounts. It allowed for consistent quoting of accurate information not previously allowed. It also reduce the average handle time by 45 seconds for the provider inquiry department. Other responsibilities included: communicating with other BCBS companies in the wellpoint network to trouble shoot issues claims between the local and guest state .