TECHNICAL SKILLS:

Technology and Tools: Microsoft Office (10+ years), Claims Processing (10+ years), Customer Service Skills (10+ years), InformationTechnology (8 years), Network Management (9 years), Administrative Assistant (8 years), Benefits Administration(10+ years), Financial Analysis (6 years), Finance (10+ years), General Office Skills (10+ years), Coaching (10+ years), Contract Negotiation (9 years), Leadership Development (6 years), Sales (10+ years), Service (6 years), Technology (10+ years), Project Management (7 years), Business Management (10+ years), Conflict Resolution (9 years), Negotiation (5 years), PowerPoint (5 years), Innovation (5 years), Financial Analysis (7 years), Dropbox (3 years), Healthcare (10+ years), Process Improvement (10+ years), Provider DataSpecialist (10+ years), Forecasting (5 years), Clerical (10+ years), Strategic Planning (8 years), Medical Terminology (10+ years), Billing (10+ years), Medical Records (10+ years), Medical Billing (10+ years), Center of Medicare and Medicaid Services (CMS) (10+ years), Administrative Skills (7 years), Administrative Support (7 years), mail handling (5 years), Financial Modeling (8 years), Financial Reporting (10+ years), Telephone Skills (10+ years), Telecommunications (9 years), Pivot Tables (1 year), Six Sigma White Belt (2 years), Six Sigma Yellow Belt (2 years), VLOOKUP (8 years), Trainer (10+ years), Coaching (10+ years), Sales (5 years), Organizational Skills (10+ years), Multi - Line Phone System (9 years), Phones (10+ years), Implementation (7 years), Lean (2 years), and Agile (2 years)

WORK EXPERIENCE:

Senior Consultant

Confidential - Atlanta, GA

Responsibilities:

• Provide subject matter expertise (SME) consultation on the design, testing, and enhancement of information product(s) including technical assistance and product development support to external and internal constituents, stakeholders, and customers. Managed Medicare Advantage products, HMO, PPO, Indemnity, special cases to provide benefit scope of a members plan to each client Research, manipulate, and prepare complex data to document benefit management program activities and reporting results. Provide oversight to data quality and feedback to various areas in order to improve service delivery and enhancement to design efforts. Develop consultative relationships and the needs of internal and external customers. Collaborate and worked closely with the Center of Medicare and Medicaid Services (CMS) to remain in compliance with the guidelines of Medicare Advantage programs and policies. Manage several Center for Medicare and Medicaid Services (CMS) Physician Bonus programs:
• Health Professional Shortage Area Physician Bonus Program (HPSA)
• Primary Care Incentive Payment Program (PCIP), Physician Quality Reporting System (PQRS)
• E-Prescribing Incentive, Surgical Incentive Payment Program (HSIP)
• Veterans’ Health Administration Hospitals
• Assist with Ad Hoc reporting to review trends for improvement processes Subject matter expertise (SME) lead and business technical expert with the planning, development, and validation of master or detail test plans and strategies Provide leadership, coaching, and mentoring s to new employees Direct the implementation of program specific information through, technology, organizational methods and procedures Consult with clients on daily basis to ensure progress is in line with business expectations Translate complex data constructively and suggest recommendations Define, identify, develop and implement information products to support strategic business and operational planning *Provide workgroup support on projects Educate customers on the value, use, and interpretation of information products Trained in Six Sigma (White and Yellow belt ), define, measure, analyze, improve, and control (DMAIC) processes to reduce lead times, waste, and cost, promote a positive work environment, improve planning and control to identify problem solutions that increase customer satisfaction. In addition, trained in Lean and Agile process methodologies. Evaluation quality improvement initiative on available software and data to deliver better business solutions.

Medical Economics - Senior Financial Analyst

Confidential - Alpharetta, GA

Responsibilities:

• Developed, managed, and provide analyses to drive the decision-making process to support business operations for internal and external constituents with respect to reporting and controlling medical cost of services provided to members. Managed the production and cost analysis information used to formulate effective network contracting and management strategies Analyzed several types of provider contracts; physician (capitated and fee for service; all claim specialties) and
• Provided financial results against budget benchmarks in addition to performing variance analyses Produced ad hoc reports to provide data information across products, segments, and network markets *Assisted network managers with the development of provider compensation and fee schedules, in addition to consultative support of rate proposals Utilized and maintained the development of pricing models and medical cost tracking tools (e.g.; CPS toolPMODEL) Provided analyses and support for planning and forecasting of medical costs including the development of gross medical trend estimates Supported the development of scoreable action items (SAI's) by identifying outlier cost issues; providing ad hoc analyses and generating ideas for moderation of trend increases Recorded results of trend analyses to provide consultative suggestions for quality improvement of the delivery systems Provided network cost support to sales and marketing teams Identified overpayments and prepared projects for recovery Worked cross- functionally with the region to support of regional operating plan targets

Senior Claim Benefit Specialist

Confidential - Cranbury, NJ

Responsibilities:

• Reviewed all health provider claim types to determine the type and nature of services provided HMO, traditional plans (PPO), managed care, Medicare Advantage, transplant, employee, and indemnity plan types Determined coverage and eligibility under a member’s plan Reviewed claim and referral submissions to apply appropriate guidelines, coding, member identification processes, provider selection process, claim coding; including procedure, diagnosis and pre-coding requirements *Familiar with Center for Medicare and Medicaid Services (CMS) claim processing guidelines (in Confidential t and out Confidential t services) Coordinated with CMS to apply correct claim payment decisions based on policy and procedures of services rendered

Customer Service Representative & Claims Consultant - Transplant Analyst

Confidential - Cranbury, NJ

Responsibilities:

• Performed customer service phone coverage when needed for inbound calls Reviewed claim information to determine the type and nature of transplant services Utilized multiple system to obtain and record claim processing Determined claim payment based on guidelines of the plan appropriate to transplant contract guidelines Coordinated with Confidential t management to obtain specific member and contract information to adjudicate claim payments accurately Supported in the of office, regional, and national goals
• Honorable receipt of for handling a special project and implementation of enhanced accuracy in claim payment for one of the largest Confidential providers