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Complaint Analyst Resume

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Santa Ana, CA

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Core Proficiencies

  • Seven years of professional experience in the healthcare industry in multiple administrative, analytical, coordinating, and logistical planning roles.
  • Advanced productivity software proficiency including: MS DOS & Windows – NT, 2000, XP; MS Office 97-2007 including: Access, Excel, PowerPoint, Word, Outlook, Project, Visio Professional, and SharePoint.
  • Excellent written, verbal, and inter-personal communication skills. 
  • Detail orientated with strong abilities to multi-task, organize, analyze and identify logistical issues, and problem solve--as well as initiate long-term process improvements and business workflow enhancements.
  • Business, financial, data, and policy & procedure analysis as well as new business implementations.
  • Healthcare Practice Management Software Skill Set: TriZetto’s Facets, ProClaim, HealthTrio Express, MC400, NICE & ILLIAD.

Professional Experience

April 2011-Current Complaint Analyst, Confidential

  • Promptly enter accurate complaint information into global complaint database including transferring data from SAP system. 
  • Communicate with other departments as needed on quality feedback from the field. 
  • Compile routine and ad-hoc reports to identify and investigate complaint trends. 
  • Maintain CATSWeb complaint database.  

September 2010-February 2011 Plan Automation Analyst, Confidential

  • Utilized internal documentation in conjunction with state legislation information to configure benefit plans within ProClaim system with a overall accuracy percentage of 98%.
  • Successfully completed monthly transactions over and above required expectations.
  • Identified discrepancies in materials and worked with Account Management to resolve in a timely manner.
  • Completed claims testing on configuration and resolved testing errors.

July 2010-August 2010 Data Analyst – Eligibility and Benefits Coordination, Confidential

  • Performed heavy volume data entry and analysis for medical group members under a large and expanding MSO.
  • Worked as a liaison between members and MSO as well as contracted health plans, Medicare, and Medi-Cal to reconcile eligibility and benefit information in the core practice management system and in proprietary databases and spreadsheets.
  • Assisted with general office and administrative duties as requested including heavy phones and real-time customer service.

October 2009-April 2010 Enrollment and Reconciliation Analyst Confidential

  • Functioned as Primary Reconciliation Analyst for eligibility and Low-income subsidy (LIS) data reconciliation.
  • Led implementation of new Medicare policies & procedures on a company wide basis.
  • Worked with pharmacy department to ensure all Medicare Part D discrepancy issues were addressed and resolved.
  • Created and executed quality assurance queries to correct issues for daily Medicare submissions.
  • Enhanced weekly logistical process for data submissions to SCAN’s Medicare Third Party Administrator.

March 2004-February 2009 Senior Business Analyst,   Confidential

  • Communicated directly with members and insurance plans on a daily basis in order to resolve benefits, eligibility, and claims issues and address requests from multiple internal departments.
  • Functioned as a product and benefits analyst as well as an eligibility and provider coordinator.  Worked closely with IT on new business implementations, requirements building, and new program deployments.
  • Functioned as the Auditing and Data Analyst in the Product and Provider departments by building and utilizing queries based on back-end Facets SQL Server database tables.
  • Provided application support, claims processing analysis, and customer service as well as provider problem resolutions.
  • Participated as lead analyst in the organization of major new business implementation spanning across four different States (Arizona, Nevada, Colorado, Oregon), and assisted with the maintenance of existing implementations across other States.
  • Participated in inter-departmental interaction with IT, Claims, Clinical, Customer Service, Provider Operations, Account Management, Sales, and Finance / Accounting departments as well as with outside Healthplan Administrators.
  • Reduced costs and manual work for the Claims and Account Management departments by successful reconfiguration of product and benefit builds in company proprietary databases and Facets--and by analysis of inter-departmental logistical processes and business workflows.

Responsible for data analysis and reporting of eligibility, coordination of benefits, and provider operations.

May 2000-June 2003   Program Coordinator and Lead Counselor, Straight Talk-Gerry House, (Santa Ana, CA)

Responsible for managing facility logistical operations including: scheduling, internal policies & procedures—as well as hiring and training new staff.

Education: Bachelor of Science in Human Services

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