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Work Background
VSP VisionSystem Analyst
Jun. 2022United StatesResearch and determine technical system implications from business user stories. Provide detailed development specifications, develop test methods, project functionality, and delivery, in line with the long term goals and objectives/architecture of GTS and VSP Global. Utilize developed knowledge of information systems, including but not limited to system flow, input and output requirement, infrastructure, and coding, in order to create technical designs which ensure business needs are met. Actively lead development cycles and/or enterprise modifications. Serve as resource and point of contact for technical team members for delivery and support of design/development cycle and post implementation. Develop technical plans and analyze, identify, plan and manage scope and risks required to meet goals of moderately complex to complex projects. Conduct impact analysis and mitigate risks. Configure application level security for planning applications in Oracle. Manage reconciliation process. Generate and manage forms, task manager, Oracle Smart View for Office worksheets, business rules, task lists, reports, and financial reporting reports.
CVS PharmacyPharmacy Technician
Sep. 2020 - Jun. 2022Crestwood, Kentucky, United States* Preparation of medications for patients * Receiving and verifying the prescriptions * Pricing and filling of prescriptions * Assisting with insurance claims processing * Sorting medications and complete inventory
Passport Health Plan - Evolent HealthProvider Reimbursement Specialist
Oct. 2013 - Jun. 2022Remote* Updates and maintains service codes, provider types and fee schedules as well as development and monitoring of policies related to reimbursement, fee schedules and service codes * Completes quality auditing of contracts to ensure claims payment accuracy, contractual compliance in support of zero tolerance for payment errors * Identifies reimbursement methodologies for all provider types. Develops implements and evaluates policies and processes related to the communication of reimbursement methodologies and the correct loading of these reimbursement methodologies into the claims payment system * Performs monthly and quarterly audits of fee schedules to ensure reimbursement is in line with DMS and CMS reimbursement umethodologies * Performs analysis and tracking trends in utilization to provide feedback for quality improvement and cost reductions * Responsible for training staff related to reimbursement and fee schedule * Responsible for auditing of provider contracts through claims adjudication * Responsible for reviewing provider appeals for correct coding * Manually price drugs using Reimbursementcodes.com and/or EncoderPro * Experience working daily in Facets, Aldera claim systems, Jira, Confluence, and Salesforce * SAS/Oracle Hyperion/Workday/ADP * Provider Claims Team Lead * Provider Claims Research Representative
Molina HealthcareConfiguration Information Management Analyst
Oct. 2013 - Jun. 2022Remote* Molina bought Passport Health Plan and employees were merged over. * Analyze and interpret data to determine appropriate configuration changes. * Accurately interprets specific state and/or federal benefits, contracts as well as additional business requirements and converting these terms to configuration parameters. * Handles coding, updating and maintaining benefit plans, provider contracts, fee schedules and various system tables through the user interface. QNXT * Apply previous experience and knowledge to research and resolve claim/encounter issues, pended claims and update system(s) as necessary. * Works with fluctuating volumes of work and can prioritize work to meet deadlines and needs of user community. * SQL - Intermediate
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