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Work Background
Insight GlobalBusiness Process Analyst
Sep. 2023United States
OptomiBusiness Analyst
Feb. 2023 - Sep. 2023Assist in the on-going evaluation of pricing and configuration for new and existing claims business rules including member benefits, claims editing, reference data and system functionality within the claims processing system
• Analyze explanation of coverage documents to assist with determining best approach for configuring benefits offered including member cost shares, deductibles and out-of-pocket maximums
• Assist in the setup of code sets and defining pre-authorization guidelines used in claims configuration to drive application of medical policy and accurate claims payment
• Liaison with applicable departments to gather claims configuration requirements and provide feedback to stakeholders regarding feasibility of claims business rule and program changes
• Collect and analyze data to assess and resolve operational obstacles to claims configuration design optimization
• Perform root-cause analysis on claims configuration issues across all products, document results and present business impact analysis for proposed claims configuration changes
• Develop explanatory information for other departments to better understand claims configuration across products
• Identify ways to enhance performance management and operational reports related to new claims configuration processes
• Monitor existing system functionality and make claims configuration recommendations, where appropriate, to maintain acceptable levels of automation in claims adjudication and accurate claims payment
• Create and run queries to assist with configuration design, unit test configuration, and root cause incorrect configuration
• Create test scripts, including regression testing cases, to validate claims configuration against source documentation
• Assist with organizing the release of claims configuration changes to production to reduce the potential for migration conflict
• Ensure the quality and integrity of claims configuration change requests using production validation and audit strategies
Blue Cross Blue Shield of ArizonaTechnical Project Manager / Business Analyst
Nov. 2022 - Feb. 2023Responsible for researching and resolving provider file claims edits. Analyze reports for any data corrections and processes for the Association. Responsible for the review of the provider files for Quality Control.
TriWest Healthcare AllianceBusiness Analyst
Nov. 2021 - Oct. 2022Phoenix, Arizona, United StatesResponsible for the accurate review, input and adjudication of specialists, ancillary, and electronic claims in accordance with outside regulations, internal production standards, and contractual obligations of the organization · Verification of claims data, and manually pricing claims as needed · Interface with Utilization Management team to resolve authorization edits · Interface with enrollment/eligibility team to resolve eligibility edits, · Interface with our configuration team to identify and resolve configuration edits · Interact with our provider relations team to resolve provider claims/contract issues, interact with our disputes/appeals team to resolve claims disputes/appeals · Uses pertinent data and facts to identify and solve a range of problems within area of expertise
TriWest Healthcare AllianceClaims Supervisor
Dec. 2018 - Nov. 2021Phoenix, Arizona Area
CognizantSenior Claims Manager
Nov. 2015 - Jul. 2017Phoenix, Arizona Area• Developing and administering a business plan, controlling expenses, and increasing profitability to meet established business goals; managing budget while meeting operational, financial and service requirements. • Measuring and reporting on service operations performance including, but not limited to, claims accuracy rates (e.g., statistical and monetary), claims cycle performance, high dollar claims, and late fees, the performance of appropriate delegated vendors and partners, and inquiries and complaints. • Implementing and maintaining policies and procedures on the claim functions that are appropriate to the management of the business client. • Participating in response to Requests for Proposals (RFPs) or Requests for Information (RFIs) and serving as the liaison for claims operations for onsite visits by prospective and existing clients. • Managing resources effectively and efficiently to support the strategic initiatives of the company. Consistently portraying the image of a role model for the department by demonstrating the highest levels of customer service, technical skills and professionalism to ensure mutually rewarding and continued relationships.
CenterLight Health SystemTeam Lead Provider Services
Nov. 2014 - Jun. 2015Greater New York City Area• Provide daily direction and communication to employees so that Provider Claims Service calls are answered in a timely, efficient and knowledgeable manner. • Provide continual evaluation of processes and procedures. Responsible for suggesting methods to improve area operations, efficiency and service to both internal and external customers.
• Provide statistical and performance feedback and coaching on a regular basis to each team member
• Be available to Provider Service Team staff by providing appropriate coaching, counseling, direction and resolution
• Insure employees have appropriate training and other resources to perform their jobs
• Provide feedback on disciplinary and/or performance problems according observations and company policy. • Assist with daily operation of the Provider Service call center to include the development, analyses and implementation of staffing, training, and scheduling. • Share continual responsibility for deciding how to manage the employees ensuring calls are handled efficiently and effectively. • Thoroughly researching all Provider Claims related inquiries received via phone, fax, email and other correspondence.
• Responsible for any follow-up work needed for these issues including any callbacks to Providers • Identify and trend misrouted and inappropriate inquiries sent/receive to the Provider Services department.
• Update and maintain all databases/spreadsheets • Provide feedback to Provider Services management team
• Serve as first point of escalation for both internal/external business partners and other customers
• Resolve escalated issues and communicates to the caller the closure of the issue
• Provide feedback, recommendations and trending information to immediate Supervisors for targeted training opportunities
• Provide assistance to Provider Service Representatives as needed
ACCENT Health Recruitment NZBusiness Analyst
Jul. 2014 - Sep. 2015Greater New York City Area• Initiate billing on assigned claims in an expeditious manner, whether through hard copy claims or electronic format. Audit claims to ensure pertinent information is captured, including authorizations, clinical notes, treatment plans etc. • Maintain control of claims billed and pending to ensure full accountability for all claims.
• Follow-up on all unpaid claims over 60 days. Analyze aging reports to identify details of open account balances. Maintain documentation of all collection activity. Advise AR Manager of workload problems which may prevent timely follow up on accounts.
• Weekly tracking of unbilled claims. Notify AR Manager of trends/issues.
• Work EOB/remittance advices on a daily basis to identify denials or short paid claims. Work with branch office designee on eligibility issues and necessary documentation to ensure timely collection of accounts.
• Demonstrate aggressive yet conscientious collection efforts. Request approval for account adjustments as appropriate.
• Submit completed refund request documentation to AR Manager within time designated by management.
• Resolve credit balance accounts on a monthly basis.
• Perform all other duties as assigned by AR Manager and/or Director of Reimbursement
EmblemHealthSenior Rates Specialist
Dec. 2013 - Jun. 2014Greater New York City Area•Ensure that all facility contracts received are accurately and timely logged within the Contract Control Log and reviewed and configured services and corresponding rates/reimbursement methodologies (i.e. DRG, APG, APC, ASC etc) in the provider contracting system
•Update provider contracts with bill types, revenue codes, CPT/HCPCS, procedure codes, ICD9/10 diagnosis codes, Per Diem and Case Rates and DRG codes on a yearly basis or as determined by the provider contract.
•Review of facility agreements and perform related functions such as request for provider demographics and reimbursement policies modifications and updates.
•Report reoccurring contracting and/or systematic issues to Lead and Manager. Support Lead and Manager with internal audits, QA audits and other standard of operational (i.e. SOX) processes audits by providing supportive documentation for review and validation purpose Collaborate in the development and implementation of solutions for opportunities for improvement. •Conduct thorough investigation of facility provider contract related inquiries received via Claims, ESAWS and Grievance & Appeals, analyze the issues involved, perform the appropriate actions accurately and response with in Service Level Agreement (SLA) time frames.
•Generates daily pended claims report, research, analyze reasons for pending claims and determine resolution as issues relates to facility contracts and system configurations.
•Attend and participate in contract review forums to discuss, evaluate and identify any contracting, configuration and or systematic processing issues and have an opportunity to provide recommendations and solutions within a team environment.
61st Street Service CorpSenior Account Representative
May. 2013 - Dec. 2013Greater New York City Area• Monitored unbilled claims report and followed up with appropriate personnel to complete information needed for bill generation.
• Reviewed system generated reports to correct billing errors for electronic submission of bills
• Routinely monitor the appeals process
• Validate successful transmission of claims to insurance carrier and intermediaries
• Contact patients and/or payers for missing demographic or insurance information needed for
• billing
• Verify insurance benefit information with all available carriers through the web sites or telephone
• Access web sites or contact payer by telephone to follow up on unpaid claims, obtain requested documentation and rebill if necessary.
• Audit account history to ensure appropriate reimbursement has been received and that contractual allowances have been accurately posted
• Follow up on third party claims to resolution or point of appeal
• Prepare third party appeals
• Make financial class changes as necessary in compliance with policies
• Review explanation of benefits or exception reports to evaluate accuracy of payment
• Ensure statements and letters are generated to patients as appropriate
• Establish reasonable payment plans according to policies; set up budget plan in system and monitor payments for consistency and timeliness
• Counsel patient on various local, state and federal agencies which may be available to assist with funding health care (e.g., bank loans, Medicaid, etc.)
• Initiates and/or directs assisting the patient in obtaining third party coverage (e.g., complete enrollment forms, obtain required documentation and follow up on eligibility status, etc.)
• Review unpaid accounts meeting dollar or time-frame thresholds prior to assignment of account to outside agency FSC
Healogics, Inc.Business Office Manager
Sep. 2006 - Jun. 2012Bronx, New York
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