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OBJECTIVE 
My objective is to obtain a position in a professional environment where my skills are valued and can benefit the organization. Ideally, I wish to have a focus in compliance for a growing organization preferably dealing in Corporate or Medicare regulatory standpoint.

SUMMARY

  • A highly motivated, results-focused Senior Medicare Analyst with over ten years of experience in the Health Plan industry. Possess strong leadership and successful team building capabilities and excellent technical, communication, presentation, and customer service skills.
  • Resourceful problem solver with proven ability to bring quick resolution to challenging situations.
  • Strategic Planning
  • Business and Product Development
  • Client and Vendor Relationship
  • Continuous Process Improvement
  • Operations
  • SME for Medicare Advantage Enrollment and Eligibility, Part D Drugs and Formulary Requirements, Late Enrollment Penalty, Annual Readiness.
  • Compliance (Regulatory and Corporate)
  • Part C and D Reporting Requirements (CMS Data Validation certified)
  • Star Rating

SKILLS

  • Communication – Serves as liaison to member services, developers, management and clients for a positive migration of all process and product enhancement.
  • Problem solving - Resolves in-depth queries in a methodical manner independently and with internal and external business partners to find appropriate resolutions, efficiencies and high level of quality.
  • Team Player - Enjoys sharing knowledge and encouraging development of others to achieve specific team goals.
  • Planning and organizing - Refined planning and organizational skills that balance work, team support and ad-hoc responsibilities in a timely and professional manner.
  • Systems knowledge – Advance knowledge of Microsoft Office and Quality Center. (Visio, PowerPoint, Excel etc)
  • Experience in preparing and analyzing reporting data for management accurately and to timescales.
  • Knowledge of end-to-end business process.
  • Advance knowledge of BRD (Business Requirement Documents), RCA (Root Cause Analysis).

EXPERIENCE

Confidential – Southborough MA March 2011 – July 2010
Senior Medicare Compliance Analyst

  • Subject matter expert regarding Medicare regulations and operational procedures.
  • Primary liaison to client health plans, the internal development and compliance teams.
  • Developed functional specifications for clients’ business requirements and CMS regulations.
  • Assisted in implementing client’s transition to Gateway portal. Smooth transition, clients is happy, no major issues. Took care some of the gaps and roadblock during implementation.
  • Supported the implementation team by providing input to the development of configuration processes.
  • Modify configuration changes resulting from testing.
  • Provide current software changes per CMS requirements and assist in configuring the system changes.
  • Responsible for BRD (Business Requirements Documents) – gathered all business and system requirements necessary for implementation of the product.
  • Diagnose process improvement opportunities, develop solutions to non-standard /moderately complex problems, provide explanations and information to others on difficult issues, and lead solution implementation in support of continuous quality improvement.
  • Managed audits, mock audits, audit universe and execute the necessary corrective action plan and training.
  • Investigates, identifies and develops policies and procedures that ensure adequate internal controls and compliance with legal and contractual requirements.

Confidential - Southborough MA February 2010- March 2011 
Senior Medicare Business Analyst

  • Subject matter expert regarding Medicare regulations and operational procedures.
  • Primary liaison to client health plans, the internal development and compliance teams.
  • Developed functional specifications for clients’ business requirements and CMS regulations.
  • Assisted in implementing client’s transition to Gateway portal. Smooth transition, clients is happy, no major issues. Took care some of the gaps and roadblock during implementation.
  • Supported the implementation team by providing input to the development of configuration processes.
  • Modify configuration changes resulting from testing.
  • Provide current software changes per CMS requirements and assist in configuring the system changes.
  • Responsible for BRD (Business Requirements Documents) – gathered all business and system requirements necessary for implementation of the product.
  • Diagnose process improvement opportunities, develop solutions to non-standard /moderately complex problems, provide explanations and information to others on difficult issues, and lead solution implementation in support of continuous quality improvement.

Confidential - Minnetonka MN November 2007- February 2010 
Medicare Operations Specialist

  • Liaison between Medica and United Health Group [Third Vendor].
  • Served as interdepartmental liaison for all MA/MAPD/PDP/Cost Medicare Enrollment/Eligibility questions.
  • Project managed all CMS requirements in Enrollment and Billing including Policies and Procedures and Medicare Enrollment Letters.
  • Interfaced with Compliance department to analyze audit findings and help prepare corrective action to our third party vendor.
  • Held Billing and Enrollment meeting regularly with Enrollment, Compliance and Member Services or other departments as needed to discuss operational issues.
  • Oversees Appeals and Grievance process including CTM [Compliance Tracking Module].
  • Kept senior management informed of ongoing progress, updates related to any CMS related Memos and new released Guidance.
  • Responsible for implementing and overseeing all Enrollment CMS requirements.
  • Developed and implemented policies and procedures which includes process flows, guide sheet for all important responsibilities as part of development of Medicare Operations Manual.
  • Supported short term operational business activities - research and analyze eligibility, other health information, and group data for issue identification and root cause, develop and test interim solutions, manage implementations, and monitor results.
  • Initiated and manage long term operational business goals - develop business case documentation, define business requirements, support business to business specifications, develop and lead user-interface testing, manage project implementation and post-production results.
  • Managed audits, mock audits, audit universe and execute the necessary corrective action plan and training.

Accomplishments: 
1. Created a process for members, who are losing their Low Income Subsidy during midyear and the end of the year. 
2. Created process for Auto-enrollment. Identified and implemented the Full Benefit Dual Eligible and Other LIS. Wrote policy and procedure and submitted it to CMS. 
3. Created and updated 35 Enrollment and Billing policies -both for Cost plan, Private Fee for Service plan, MA and MAPD plans
4. Created, implemented process for Late Enrollment Penalty and created 130 letters in accordance with the new 2008 model letter from CMS. 
5. Implemented the 21/30 day timeframe for requesting information for members who have incomplete information on their application form. 
6. Changed previous process for Special enrollment Period and implemented a new one according to CMS Enrollment guidance. 
7. Created and updated 60 letters for our Cost product and Private fee for Service products. 
8. Created a work-around on the Employer Group Subsidy temporary rejection by CMS by revising the model letter provided by CMS. This process eliminated a lot of phone calls from prospective members thus saved our company a lot of money.
9. Project managed the new CMS requirements with our Third Party Vendor: (1) for Marketing Material Envelope Statement, Disclaimer and Plan Type; (2) 2010 Service Area Reduction.
10. Lead the project on the Broker Receipt Date requirement changes on the 2010 application forms.

Confidential- Eagan MN August 2006- November 2007 
Medicare Eligibility Specialist

1. Assisted in the development, implementation and review of Medicare enrollment and eligibility policies. 
2. Resolved member eligibility issues. 
3. Worked on ad hoc projects such as PDE. 
4. Support short and long term operational/strategic business activities - by developing, enhancing and maintaining operational information and models.

Confidential- Burnsville, MN November 2005 - August 2006 
Admission Financial Representative

1. Responsible for registering Urgent Care patients within established guidelines. 
2. Verified insurance for incoming patients.

Confidential- Eagan, MN May 2001 - September 2005 
Enrollment Specialist II / Biller

1. Analyzed and reconciled various types of accounts receivables related to Enrollment processing. 
2. Processed enrollment data into the membership system. 
3. Processed credentialing and re-credentialing applications for all providers of the multi-specialty group practices of in accordance with department expectations, credentialing policies and procedures and regulatory requirements. Works closely with internal and external customers ensuring the credentialing process is completed within a deadline intense environment.
4. Set up small group contracts.

Confidential- Eagan, MN January 2000- May 2001 
Membership Eligibility

1. Researched analyzed and resolved membership applications. 
2. Responsible in reprocessing claims for the third party administrators.

EDUCATION 
Bachelor in Science

PROFESSIONAL MEMBERSHIP
Health Care Compliance Association - Current

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