PROFESSIONAL SUMMARY:

• Experienced, versatile and detail oriented Healthcare claims professional with 20+ years experience; 11 of those years working as a contractor and/or temporary positions for Health Insurance Companies in all phases of their business cycle’s and processes, ie. Adjudication, auditing and/or adjusting of claims, contract configuration and Testing
• Knowledge of Medical Terminology, use of correct CPT and ICD9/10 Codes, Claims Adjudication, Auditing, System Testing, Integration Testing, Test Case Development, UAT and Business Analytics on multiple system’s and project’s. Function’s well in a fast paced environment. E2E Testing, Test Planning, Functional Testing
• Dedicated, hard - working individual that works well within a Team in order to maintain teh business functions of any claims related activities, including claims monitoring, payment disputes, escalated provider inquiries, and system claims system configuration
• Experience as a Testing Team Lead, Health Care Trainer, Adjustor, Auditor, Tester and Test Coordinator.
• Knowledge of teh phases of software development life cycle (SDLC) or application development life-cycle such as Waterfall, Agile and Hybrid SDLC Models
• Subject Matter Expert that allowed me to guide/mentor Teams in processes, procedures and functions which in turn helped them achieve their milestones and/or deliver their products on time and with quality
• Mission-driven, as well as enthusiastic individual with diverse areas of expertise, working toward helping solve teh complicated problems in teh healthcare/claims industry
• Provide mentorship and leadership to teh Team in order to consistently meet established productivity and adherence to quality standards.
• Ability to accept and/or acknowledge accountability and a sense of ownership in heping guide/assist a Team in a meaningful direction that teh Team can impact teh business in a healthy way
• Ability to collaborate with management and/or Team members to ensure best practices are followed and actively and continually seek efficient and innovative processes and technology to enhance operations by optimizing all resources

TECHNICAL SKILLS:

Microsoft Office Suite, SharePoint, Outlook, HPQC ALM 11.0, JIRA, Diamond, Facets 4.71 up to Facets 5.30 R3, Trizetto NetworX/NetworX Pricor pricing, Nasco, QNXT, TFS, EZ Cap, UB, HCFA, Medicaid, Medicare, Commercial, Highpoint Tool; Optum EnCoder Pro for Payers.

PROFESSIONAL EXPERIENCE:

Confidential

QA/UAT Testing

Responsibilities:

• Worked with managers for eligibility, provider setup, and medical policy/configuration.
• Reported audit findings on a frequent basis to managers.
• Ensured errors were identified and corrected quickly.
• Updated tracking and reporting process for audits and shared findings with teh Team and manager.
• Helped to identify and report teh process improvement opportunities to increase performance, and quality.

Environment: QNXT; SharePoint; Claim Central; Microsoft Outlook

Confidential

Claims Specialist/Auditor

Responsibilities:

• Working C70 pended claims, which are claims that are resubmitted for various reasons, such as changed/updated procedures, diagnosis claims, etc.
• Utilize excellent analytical and problem-solving skills.
• Research and reprocess medical and/or dental claims in accordance with Plan Benefits, Federal and State mandates, and applicable internal Standard Operation Procedures.
• Manually price claims per teh contract description for IP and OP claims; manually price Medicaid spend down (patient liability).
• Work all New York hospital claim; IP, OP; SNF, Rehabilitation claims.
• Assist team members with questions and shadow on how to improve quality and quantity.
• Meets or exceeds teh following quality metrics: 99% Financial Accuracy; 98% Payment Accuracy; and 98% Procedural Accuracy.
• Participate efficiently in processing teh flow of claims: inform teh Claim Supervisor about claims lacking clarity and about possible ways of optimizing teh processes
• Track irregularities in procedures and highlight areas that need to be reprocessed/worked.
• Maintain audit sheet for 3 Teams; audit 5% of claims processed by each Team member in 11 different plans and states.

Environment: QNXT; SharePoint; Claim Central; Teh HUB (client P&P); Microsoft Outlook

Confidential

UAT Team Lead/Tester

Responsibilities:

• Created Test Plans, Test Scenarios and Test Cases
• Conducted Walkthrough of Test Plans, User Stories and Test Cases to Confidential Client.
• Verified Execution of Test Cases
• Participated with teh Project Team of all testing on a daily basis.
• Assessed teh Types of Testing to be performed, ie. Functional, Regression, etc.
• Impacted teh number of Test Cases to be Developed and Executed based in teh scope of teh Requirements per LOB.
• Performed Defect Management.
• Developed and Reviewed teh Test Evaluation Summary Document with teh Project Stakeholders.
• Created Data in Facets to be used for Test Execution
• Trained 4 team members how to access and create members in Facets for use in Test Execution

Environment: Facets, JIRA, Hyperion/Brio, SharePoint, Skye for Business, WebEX

Confidential

UAT Tester

Responsibilities:

• Compare claims in system to EOB that is created to verify all information is accurate and correct. Created test scenarios; developed appropriate test cases; assisted with and reviewed test requirements and assisted with preparation of test data.
• Created and resolved defects and issues related to EOB documentation
• Review and audited all in scope UAT Requirements to verify accuracy of information recorded by UAT Testers.
• Organize, Process and Summarize Data to identify trends, patterns and outcomes in support of project initiatives
• Assisted AEP (Annual Enrollment Period) UAT Team in CCR (Configuration Change Request) Testing.
• Supported teh Team Lead in maintaining teh UAT Team Tracker as well as UAT Bug Tracker, additionally assisted in identifying issues that would impact timeliness.
• Performed other duties as required or assigned.

Environment: QNXT; SharePoint; OnBase; Change HealthCare Client Access System; Microsoft Outlook; SQL

Confidential

Appeal Adjuster Specialist

Responsibilities:

• Analyze and research claim disputes to determine teh decision, including underpayment, overpayment, correct denial, incorrect denial, verify correct usage of CPT/ICD codes, to correctly reimburse teh claim based on contractual or non-contractual reimbursement.
• Conducting claim research, identify and resolving issue.
• Update created case in teh GTESS or HealthX to document teh claim research findings and decisions.
• Examine teh claim with evidence and determine teh validity of teh claim against teh billing requirements from both Confidential and CMS.
• Systematically triage claims through built-in workflow that require Medical Necessity review to Post-Service clinical team for medical record review and decision.
• Systematically triage claims through built-in workflow that require investigation on specific claims edit to Code Edit team for confirmation and decision.
• Systematically triage claims through built-in workflow that require adjustment to teh claim.
• Appeals and adjustments done on FFS claim reimbursement, billing and reimbursement methodology for Facility and Professional (UB-04 and CMS1500), including but not limited to inpatient hospital, outpatient professional, SNF, ASC, DME, Home Health, etc. claims.

Environment: Amisys, GTESS, HealthX, 3M, PVM,TMHP Amiseek

Confidential

QA Tester / QA Team Lead

Responsibilities:

• Claim processing Subject Matter Expert
• Created and edited content in Sitecore (Content Management System)
• Personalization testing of Sitecore 8
• Document and implement test strategies, plans, processes and standards
• Execute testing plans/strategy, create test cases, and user acceptance criteria
• Created Use Case Template; assisted in created Use Case
• Importing test cases from Excel to HPQC ALM
• Exporting test cases from HPQC ALM to create spreadsheets for test cases
• Assisted 6 Departments in writing test cases for execution
• Assist with Test execution during test life-cycle
• Maintain teh defect management life-cycle, using JIRA and HPQC
• Responsible for quality assurance and revision of approximately 1600 test cases.
• Responsible for quality assurance of data input in Sitecore to transfer to Member Web Portal

Environment: Amisys, HPQC ALM 11.0, Sitecore, Workfront, JIRA, Basecamp

Confidential

Configuration Analyst II

Responsibilities:

• Conduct analysis of claims related issues and determine resolution needed within set timelines.
• System configuration of contracts to be migrated from Facets to NetworX pricing.
• Assist as part of a team to update Facets Service Rule Definitions.
• Assist as part of a team to load group structure data.
• Assisted in loading and updating Plan descriptions and Class/Plan definitions..
• Facets and Claim processing Subject Matter Expert.
• System and Integration Test Case Development and Execution.
• Created test case scenarios, as well as executed test cases.
• Peer Review on Agreements completed and ready to data transfer from Configuration to all environments (i.e. Dev, Cert, VINT, and Production).
• Research Facets to locate Facilities and Agreements
• Data Transfer Agreements into all environments (i.e. Dev, Cert, VINT, and Production).
• Updating and creating Subgroups within Groups.
• Adding and Updating NetworX Qualifier Groups

Facets 5.1; Facets 5.2 R4 Facets 5.30 R3; SharePoint; NetworX Pricer; Microsoft Lync; Outlook; Optum EnCoder Pro for Payers

Confidential

Senior Test Specialist

Responsibilities:

• Facets and Claim processing Subject Matter Expert for a Team of 10 Testers (On Site and Off Site)
• Managed UAT Test Case Development.
• Assisted in preparation for Regression Test Case Development.
• Responsible for quality assurance of approximately 1800 test cases.
• Responsible to QA/audit all test cases executed by IBM
• System and Integration Test Case Development and Execution.
• Single point of contact to resolve potential defects found in all IBM Testing Phases.
• Review defects, verify legitimate and notify BCBST Defect Manager of review readiness.
• Review defects returned to Team to verify defect had been fixed and Test Case could be executed.
• Provided to teh Test Teamswhen required as well as developed end user Testing Documents/Cookbooks
• Mentored new Test Team members as part of teh on boarding process for BCBST/IBM.
• Back up to teh IBM Test Manager on any escalated issues.
• Developed and communicated status reports on a daily basis to teh upper IBM Management Team.
• Testing SME on teh Highpoint ICD-10 Provider testing tool and ICD-10 Provider Facility Testing Tool.

Environment: Facets 5.1 and Facets 5.2 R4; HPQC; Access Mapping Tool; SharePoint; Highpoint ICD-10 Provider Testing Tool; Highpoint ICD-10 Facility Tool; NetworX Pricer; Provider Pricing and Contract Tool; IBM Lotus Notes; IBM IPWC Repository, Blueprint; Optum EnCoder Pro for Payers

Confidential

Epic Tapestry Configuration Team Lead

Responsibilities:

• Knowledge and understanding of various provider contracting arrangements and/or benefitsadministration data elements that need to be configured in teh existing application (teh host processing system).
• Knowledge, and understanding, of other platform applications to support teh accurate and timely payment of claims for teh Regions' Claims systems.
• Test new releases, makes recommendations on system enhancements, and evaluates contracts for configuration which includes system capabilities.
• Perform configuration activities which may include: Institutional and Provider Contracts, Benefits Authorizations, and/or general configuration such as System Edit Rules, Fee Schedules updates, in Epic Tapestry Claims Processing system resulting in 100% claim payment consistent with teh contractual arrangement(s) made with teh provider(s) and according to teh Groups Evidence of Coverage .
• Ensure teh provider, authorization and benefits configuration meets established business rules and procedures.
• Modification of provider contract, authorization rules and benefit plan configuration as required.
• Load new contracts, authorizations, and benefit configuration into Epic Tapestry module.

Environment: Epic Tapestry

Confidential

Supervisor/Trainer/Adjustor

Responsibilities:

• Assisted in creating PowerPoint and Word documents utilized in step by step .
• Updated and provided Teams with all documents used by UHC.
• Trained team on TennCare product and contracts utilized by UHC.
• Supervised and trained a team consisting of 23 team members.
• Provided one on one for team members in need of further assistance.
• Dispensed work to Team.
• Researched and to determine if claims were paying correctly and adjusted claims to pay correctly when necessary.

Environment: Facets; Knowledge Library; Automated Resolution Utility; IDRs; HIPAA Repository; Outlook; SharePoint; Lync

Confidential

Claims Liaison

Responsibilities:

• Coordinates documentation, tracking and resolution of all plan providers’ billing and payment issues.
• Provides expertise and researches verbal and written providers’ claims inquiries from plan and corporate staff.
• Provides expertise to Provider Services/Relations in teh identification of Medical Management authorization issues and trends.
• Utilizes knowledge of provider billing and claims processing, directs Provider Services/Relations with teh claims reprocessing notification.
• Track trends in claims processing issues and assists Claims Department in identifying and quantifying issues along with reviewing Claims Department work processes as requested.
• Identified providers and provider types experiencing a large number of claims issues or with teh potential to develop claims issues and proactively work to eliminate barriers for accurate and timely claims processing.
• Notify teh plan staff of any claims system or procedural changes in a timely manner.
• Document (in CRM) all provider inactions and monitor teh Provider Relations/Services CSF queues and make any changes as necessary.
• Run claims reports regularly through provider information systems (Business Obs and Amisys)

Environment: - Amisys 6.0, Amisys Advance, CRM, AWD, Business Obs, Webstrat, Portico, Emdeon, Microsoft Office Suite, Outlook, Sametime, Service Now, Share Point, Microstrategy

Confidential

Claims Research Analyst

Responsibilities:

• Perform research on claims inquiries and reprocess claims as needed.
• Recover funds from providers due to overpayment, and adjust provider claims for overpayment and/or underpayments. Communicate with providers regarding claims recovery and adjustment issues by telephone and/or in writing, as appropriate. Liaison to corporate finance department concerning claims recoveries and adjustments in regards to issues.
• Assist supervisor in teh review of various claims reports; follow up and resolve errors.
• Assist in system issues e.g. contract and benefit terms, edits.
• Verify member other coverage by calling insurance companies, provider offices, or members.

Environment: - QCare, Xcelys, Macess, Webstrat, Check Log, Microsoft Office Suite, Outlook, Sametime

Confidential

User Acceptance Tester

Responsibilities:

• Test system, evaluate claims adjudication needs
• Work EDI X12 transaction sets 837 I/P
• Validation P2W claims
• Validate all information transferred from HCFA/UB from Edoc environment to claims environment
• Work with IT to conduct testing to meet project timelines
• Verify provider information and claim payment information
• Organize, process and summarize data to identify trends, patterns and outcomes in support of project initiatives

Environment: - Amisys, Macess, Novell, Microsoft Office Suite

Confidential

Claims Specialist

Responsibilities:

• Processed electronic physician/outpatient hospital claims
• Determined whether to return, pend, deny or pay claims within policies
• Re-processed claims requiring adjustments
• Followed established departmental and procedures, operating memos and corporate policies to resolve claims and claims issues
• Worked routine claims pending reports
• Interpreted and communicated explanation of benefits (EOB) statements from other carriers to facilitate coordination of coverage
• Entered claims in Viant and Enteprice Multiplan Pricing environments to get negotiated rates

Environment: - Amisys, Viant, KIF, Enteprice Multiplan Pricing, Outlook

Confidential

Claims Specialist

Responsibilities:

• Review and process claims for active and retired employees against multiple plans/systems and various provider networks for completeness and accuracy
• Types of claims include medical, vision, COBRA, WC, and subrogation
• Review of payment screen to verify accuracy of member and provider addresses; accuracy of system's automated Type of Service code assignments (which determines service line-level benefits) and override when necessary to ensure proper benefit application
• Review of payment screen to verify accuracy of system's automated Type of Service code assignments (which determines service line-level benefits) and override when necessary to ensure proper benefit application
• Verify all family members listed and social security numbers are obtained
• Verify claims history for duplicate claims
• Determine if letters need to be sent to member and provider for coordination of benefits, subrogation, and workers comp
• Send out letters for medical necessity and legal documents when needed
• Received COB claims and information with COB indicators and processed claims according to coordination of benefits guidelines, included Primary/Secondary, Medicare and Medicaid.

Environment: Claimsfacts, Claimflow, Excel, Outlook

Confidential

Claims Analyst III

Responsibilities:

• Worked adjustments; calculated interest, as well as worked teh correspondence queues for adjustments and contact service form queues
• All adjustments started with teh following keying verifications; member and provider information, all service line information, diagnosis and procedure information to be correct, as well as units and placement of pointers
• Verification of all inpatient and outpatient information on UB forms
• Verified all dates for original filing and adjustment filing meet timely filing guidelines
• Check for attachments, look up notes and remarks on claim, determine reason for adjustment
• Work from Access and Excel on special project spread sheets for single and multiple provider adjustments for contract updates or overpayments on contracts
• Determined if letter needed to be sent to provider for more information or if timely filing not met for adjustment

Environment: Amisys, Webstrat, Macess, Excel, Outlook

Confidential

Audit of HCA Accounts

Responsibilities:

• Identified and/or verified opening and closing balances, additions and subtractions, and retroactive adjustments within teh current reporting period year to date on Consumer Driven Health Plans (CDHP)
• Identify coverage for those members who are utilizing their HCA accounts through incentives and rewards programs
• Identify individual employee/employer HCA account balances, coverage, account claim activity, deductible amounts
• Once funding is identified as accurate claims are closed as quality
• Pend problem accounts for manual correction

Environment: Web App Bluestar, Bluechip, CMMouse, Prime Therapeutics, BAM (Blue Access for Members), Lotus Notes, Excel

Confidential

Customer Service Specialist PFFS

Responsibilities:

• Verifying eligibility and enrollment and verifying claims status for members, brokers and providers;
• Updated information and forwarded to enrollment for processing of enrollment for members
• Providing forms for members on changing their payment plans and dis-enrolling in plan
• Looking up hard copies of enrollment applications; claims and other documents in Epitome for brokers, providers and members
• Verifying benefits for members and providers on inbound calls and verifying enrollment and explaining plan to members on Outbound calls

Environment: Trizetto, QNXT, Sametime, Access Online, CMS, NPPES NPI Provider Verification, Rightfax, Call Master Phone System, TAPS, ICARE