Sonja Angel Email & Phone Number

The Claims Audit Unit transitioned from Internal Audit to Operations to create a new department focused on quality, operational process improvement opportunities, and compliance to Medicare/Medicaid requirements and regulations. Additional responsibilities added to this role include:• Monthly audits of TMPSCO and TMPHMO claims, for compliance to CMS requirements and regulations.• Additional weekly audits or TMPSCO claims to provide feedback on administration of TMPSCO as it pertains… Show more The Claims Audit Unit transitioned from Internal Audit to Operations to create a new department focused on quality, operational process improvement opportunities, and compliance to Medicare/Medicaid requirements and regulations. Additional responsibilities added to this role include:• Monthly audits of TMPSCO and TMPHMO claims, for compliance to CMS requirements and regulations.• Additional weekly audits or TMPSCO claims to provide feedback on administration of TMPSCO as it pertains to internal policies and procedures as well as Medicare/Medicaid regulations.• Provide internal reporting for performance guarantees with employer groups.• Work with Operations management team and numerous departments throughout the organization to address process improvement opportunities, directly impacting quality scores. • Perform targeted audits to determine accuracy of employer group benefit set ups, as requested by the Senior Management Team.• Perform a quarterly high cost claims audit to support Claims Operations with satisfying an Internal Audit requirement. • Implemented a resolution project management process to identify the root cause of audit errors for Commercial and TMP claims. Identified $1.9M in process improvement opportunities in the first 2 years Show less

• Developed a highly skilled, versatile team of up to 7 independent auditors who analyze, evaluate and research samples of claims for all Tufts HP products to ensure payment accuracy and compliance with Medicare, Tricare, contractual arrangements with employer groups, members, and providers, as well as internal policies and procedures. • Managed and guided a claims audit team that is considered to be an industry model for reporting on quality, and has identified millions of dollars in… Show more • Developed a highly skilled, versatile team of up to 7 independent auditors who analyze, evaluate and research samples of claims for all Tufts HP products to ensure payment accuracy and compliance with Medicare, Tricare, contractual arrangements with employer groups, members, and providers, as well as internal policies and procedures. • Managed and guided a claims audit team that is considered to be an industry model for reporting on quality, and has identified millions of dollars in claim overpayment and underpayments.• Implemented Automated Command Language (ACL) to create and maintain weekly, stratified, random audit samples for internal management and customer reporting. . • Recognized for developing and maintaining a multi-departmental audit process that supports employer groups who come on-site to perform client specific audits.• Maintained and enhanced audit documentation and data tracking tools to support the changing needs of the organization.• Issued audit results and reporting that are consistently relied upon by E&Y for purposes of SSAE16 and year end financial audit reporting, saving the organization significant time and costs that would otherwise be billed by the external auditors. • Identified millions of dollars in overpayments resulting from a new pricing system implementation.• Identified millions of dollars in overpayment and underpayments on specialized high cost audits, requested by an internal finance department• Facilitated the self-training of the Claims Audit Unit on a new pricing tool used by the organization to pay claims, while still maintaining timely reporting.• Developed a versatile and highly respected staff personally by recommending challenging internal and external training opportunities and coaching them throughout their development. • Formalized quality assurance procedures to ensure all audit work is accurate, complete, and well documented.. Show less

• Lead resource to the Claims Audit Unit responsible for evaluating staff in all aspects of multi-product claims audits. • Scheduled and prioritized claims audit work to ensure timely reporting. Ensured that all audit work was accurately and completely documented and met audit standards.• Assumed management responsibilities in the absence of the Claims Audit Manager for an extended period.• Performed detailed analysis on multi-product claims to assess the accuracy of benefit… Show more • Lead resource to the Claims Audit Unit responsible for evaluating staff in all aspects of multi-product claims audits. • Scheduled and prioritized claims audit work to ensure timely reporting. Ensured that all audit work was accurately and completely documented and met audit standards.• Assumed management responsibilities in the absence of the Claims Audit Manager for an extended period.• Performed detailed analysis on multi-product claims to assess the accuracy of benefit administration, claim payments, and internal processes. • Worked with Operations Management to develop proposed solutions to improve the quality of claim adjudications. • Assisted the Claims Audit Manager with the coordination process of external audits from employer groups. • Performed specialized provider group audits to ensure contract compliance and quality service.• Trained 6 new staff on all products and developed existing staff. Show less

• Analyzed claims on four different computer applications.• Evaluated and researched claim samples for payment accuracy, completeness and compliance to state and federal regulations.• Independently determined the extent of testing and research required to properly audit all claims.• Performed statistical analysis on individual claims for provider groups, and monitored performance goals of business groups to ensure contractual compliance.• Analyzed state employee plans, HMO… Show more • Analyzed claims on four different computer applications.• Evaluated and researched claim samples for payment accuracy, completeness and compliance to state and federal regulations.• Independently determined the extent of testing and research required to properly audit all claims.• Performed statistical analysis on individual claims for provider groups, and monitored performance goals of business groups to ensure contractual compliance.• Analyzed state employee plans, HMO, PPOs, Tufts HP Medicare Preferred, and large business plans across THP’s seven health plan products.• Consistently selected to perform important and deadline-oriented tasks.• Wrote policies and procedures manual and computer operation instructions, which were well received by management and incorporated into the company training manual.• Consistently achieved top performance reviews and was directly promoted to Supervisor in 2+ years. Show less