SUMMARY:

• Financial/statistical/operational/actuarial analyst with an established work history, mostly in the healthcare industry.
• Areas of expertise include data analyses, quantitative reasoning, and risk models.  Strong problem - solving, math and teamwork skills.

TECHNICAL SKILLS:

• Financial/Statistical modeling
• Risk/Quantitative analysis and trend forecasting
• Streamlined process automation and improvement
• Data mining - Access, SQL
• Advanced Excel - pivot tables, lookups, sumifs
• Programming - VBA, macros
• Executive presentations - Powerpoint
• Business Intelligence - Tableau, Power BI
• Healthcare industry-specific proficiency:
• Medicare, Medicaid, ACA/CCI
• CMS, HIPAA, NCQA, OSHPD
• EMR/EHR, Meditech, eCW, QNXT
• DRG/CPT/ICD-10/HCPCS, HEDIS
• Managed care, HMO, PPO
• Capitation, fee-for-service
• PMPM, MLR, ALOS, Rx scripts, readmissions
• CMS 5 Star

PROFESSIONAL EXPERIENCE:

Senior Financial Analyst

Confidential, Long Beach, CA

Responsibilities:

• Executed objectives of the corporate FP&A group, focusing on Medicare line of business. Individual contributor for developing financial analytics of internal and external data, variance analysis, KPI examination, modeling, forecasting and budgeting.
• Notable accomplishment: comprehensive claims analysis of hospice members in 2016 that realized a potential $1.9 million additional CMS reimbursement. Similar study initiated for ESRD members.
• Created and analyzed existing and potential workflows, processes, supporting systems and procedures, and identified opportunities for improvement and standardization.
• Evaluated risk and return of various business scenarios for profit optimization.
• Procured reports and analyses in performance evaluation, including the monthly Medicare performance report package.
• Built models to forecast and budget future finances.
• Interceded in the accurate and timely processing of Rx claims between contracted vendor (CVS), internal Membership Accounting department and CMS.
• Analyzed financial and utilization trends.
• Documented business processes and procedures.

Decision Support Analyst

Confidential, Encino, CA

• Queried databases and generated clinical and financial reports for business operations and internal management, as requested by different company personnel.
• Maintained and updated data crosswalk tables internally used for data querying.
• Monitored data warehouse updates.
• Worked with management to prioritize, synthesize and define information needs, translating needs into data specifications.
• Assisted with HEDIS data procurement for P4P initiatives.

Financial Consultant

Confidential, Monterey Park, CA

• Developed and implemented processes for accounting and finance activities of the company that provides managing services to healthcare organizations such as independent physician associations (IPAs) and medical groups, hospitals and hospital groups, and health plan providers .
• Notable accomplishment: established an Excel-based reconciling tool that checks the accuracy of the monthly capitation premium payments received by client IPAs from contracted health plans. This Excel-based reconciling tool achieved the objective that otherwise sought-after proprietary systems performed, thus, saving the company from an additional vendor cost. Said tool was instrumental in identifying a $900K payment shortage over a 2 year period.
• Solved difficult problems and issues where analysis of situations or data requires an evaluation of intangible factors, innovative solutions, and collaborates with other business partners.
• Reconciled revenue sources - capitation, fee-for-service claims, risk pools, P4P, OB kicks - for accuracy and timeliness.
• Reviewed provider contracts in different lines of business; identified areas of potential financial improvement.
• Calculated monthly IBNR.
• Completed special projects and deliverables as assigned.

Clinical Analyst

Skilled Healthcare, Foothill Ranch, CA

• The sole analyst of the Professional Department, provided all-around performance monitoring analyses of the company’s long term care affiliate facilities, focusing on quality care improvement.
• Oversaw clinical and managerial performance reporting tools, including CMS’s 5 Star Rating System-related models.
• Performed 5 Star-related studies and trend analyses.
• Identified key performance indexes and correlates these facility KPIs to its 5 Star rating.
• Assured the accuracy of publicly reported clinical outcome measures, addressing the correction of erroneous information.
• Administered the procurement of automated clinical outcome reporting tools.

Financial Analyst,

Confidential, Orange, CA

• Upheld the analytical activities within the organization under the directions of the Chief Finance Officer.
• Notable accomplishment: cost per service analysis of surgical abortion. Not only were the analysis findings (together with those from other service lines) used in the development of a sliding fee scale pricing of provided services, but also spearheaded a surgical abortion service line pricing standard for other Planned Parenthood affiliates.
• Sustained the implementation of managerial accounting information such as budgets, cost accounting, procedure margin analysis, etc., as well as support operations with productivity information.
• Developed service line cost and profitability analyses, forecasts and revenue projections.
• Conducted price and rate analysis based on costs, and assists in the development of the sliding fee scale.
• Analyzed productivity and work load assessments, identifying improvement opportunities with Patient Services.
• Composed financial and operational analysis procedures manuals.

Decision Support Analyst

Confidential, Ontario, CA

• Managed financial and statistical reporting for the organization to comply with the statutory requirements and in support of senior management’s goals and objectives.
• Uploaded and maintained financial and statistical data into company-wide central database and accounting systems.
• Prepared financial and statistical reports for senior management and as per regulatory (OSHPD) submission needs.
• Created models and templates for ongoing reporting tools and structures.
• Procured profit and loss analyses of KPIs of revenue departments and procedures.
• Queried databases and generated reports and analyses as needed.

Actuarial Analyst

Confidential

• Over 8 years of analytical experience in the healthcare industry, with a focus on pricing, product development and financial projections for both group and individual commercial business.
• Notable accomplishment: ownership of actuarial pricing and all pricing-related tasks for the Federal Employees Health Benefit Plan (FEHBP), which is the company portfolio’s biggest commercial plan offering in several states.
• Established fully insured commercial health insurance rates on both PacifiCare and Confidential licenses.
• Maintained rates and rating factors in PacifiCare’s and United’s large group rating models.
• Evaluated loss ratio experience relative to pricing assumptions, thereby forecasting claims costs and premiums.
• Updated rating factors methodologies to meet profitability targets, given emerging experience and projected trends.
• Developed rates for new commercial and ancillary products, as well as custom benefit offerings.
• Created healthcare cost/trend development guidelines and trend projections.
• Prepared rate filings and actuarial certifications.
• Maintained pricing integration activities, including alignment pricing factors, rating methodologies and and underwriting tools.
• Worked with underwriting and IT departments to monitor strategy initiatives and communicate reporting needs.