Experience

Managed Care Systems, Inc.

• United States
• Software Development
• 1 - 100 Employee

• Business Analyst

  • Jun 2021 - Present

  Expert in gathering business requirements and implementing solutions that ensure accuracy and automation. My roles have given me experience in a wide variety of healthcare transactions and processes: enrollment, authorizations, case management, customer service, notifications, repricing, adjudication, capitation, payments, billing, reporting, reimbursement, ACH/EFT, banking, web services, system admin, and much more. Software Products I've worked on include: Visova, Impact, Comlink Expert in gathering business requirements and implementing solutions that ensure accuracy and automation. My roles have given me experience in a wide variety of healthcare transactions and processes: enrollment, authorizations, case management, customer service, notifications, repricing, adjudication, capitation, payments, billing, reporting, reimbursement, ACH/EFT, banking, web services, system admin, and much more. Software Products I've worked on include: Visova, Impact, Comlink



Auxiant

• United States
• Insurance
• 1 - 100 Employee

• Provider and PPO Network Maintenance Team Lead at Auxiant

  • Aug 2020 - Jun 2021

  Responsible for training other routing and repricing specialists. I created effective work flows that resulted in as much system automation as possible.

• Senior Routing and Repricing Specialist

  • May 2019 - Aug 2020

  Subject Matter Expert for all in house fee schedules. Responsible for configuring our system to insert allowed amounts on claims based on the in house fee schedules which requires a firm understanding of claims billing practices. I reprice claims for DRGs, outliers, and modifiers that reduce the reimbursement amounts manually. Training routing and repricing specialists is also my responsibility which includes maintaining a library of reference documents and guiding any new employee through all policies and procedures. The training process also includes comprehensive auditing to ensure accuracy throughout.My role also includes numerous other duties:-Monthly reporting to a significant number of Auxiant's groups. This includes both running and auditing the reports for accuracy. I-Assisting in the implementation of new groups that join Auxiant. Setting up their stop loss contracts in the claims adjudication system, ensuring any individual specific deductibles are reflected accurately for each group and individual members is also my responsibility.-Responding to inquiries from providers and customers regarding network and pricing status for claims.-Auditing claims that are automating through our repricing engine, and being manually priced by the Routing and Repricing team.-Comprehensive evaluation of all opportunities to gain efficiencies in our processes on a regular basis. This means I don't spend all my time looking from the outside in. I get in there and do the work so I truly understand where improvements can be made. Show less

• Stop Loss Coordinator and Repricing Specialist

  • Aug 2016 - May 2019

  -Running reports weekly to identify stop loss cases -Filing stop loss cases to the stop loss carriers -Work on pending information requested from the carriers -Balance accounts at contract year-end -Order work status at 50% of specific deductible -Audit transmittals -Run monthly reports of employer groups who pay up front -Copy documentation that is needed to file the claim -Record data as it pertains to stop loss submissions -Build and maintain the PPO network connections to ensure appropriate discounts are applied to claims for automatic adjudication -Manually apply repricing to claims that are unable to automatically adjudicate due to incomplete, illegible, or missing information from the provider. -Audit invoices received from PPO networks to ensure payments are made only when appropriate. -Provide network pricing information for worker's compensation claims. -Manually generate a per claim fee invoice for specific claims and issue payment to PPO networks on a monthly basis. -Create reports for groups with aggregate only stop loss coverage on a monthly basis. Throughout my time at Auxiant my responsibilities have continued to expand. I’ve created or helped create numerous auditing processes within the various tasks I’ve been assigned. This has directly impacted our ability to catch any errors and ensure accuracy in the claims adjudication process. Show less



Dean Health Plan, Inc.

• United States
• Insurance
• 300 - 400 Employee

• Utilization Management Technical Assistant II

  • Feb 2016 - Aug 2016

  Review incoming prior authorization requests.Determine if request is needed based on Dean Health Plan medical policies.Contact providers if additional information is needed for prior authorization determination to be made.Respond to all requests in a timely mannerAnswer incoming phone calls regarding prior authorization status and generate requests for medical directors to follow up with providers regarding denial disputes.

• Customer Operations Team Lead

  • Jul 2013 - Feb 2016

  Review daily claims inventory and assign claims requiring the most immediate attention to claims staff to be worked. Handle the following types of Health Insurance claims:High Dollar Claims-Follow strict guidelines to ensure we are Model Audit Rule compliant.Transplant Claims-These are closely related to High Dollar claims and require special attention as claims from specific providers require special pricing from Optum.Repricing-Working with claims repriced by MultiPlan and applying appropriate allowed amounts to the claims prior to release.-Claims department point of contact for MultiPlan when items need urgent attention.Coordination of Benefits-Processing electronic claims transactions and reading EDI files to apply other health insurance allowed and denied amounts to the claims.Authorizations-Review claims to determine if an authorization on file matches the claim received.-Ensure appropriate procedure and diagnosis codes are on claim and the dates of service match the authorized dates of service. -Review when a claim contains ancillary services which may not require their own authorization to processClaims Investigation-Ensure compliance is maintained when processing all claims. This includes ensuring proper Medicaid consent forms are received when applicable, ensuring authorization guidelines are followed, ensuring proper documentation is received supporting services rendered.Special Investigation Unit-Process claims per SIU instructions. Approving and denying claims as appropriate based on SIU review.Timely Filing-Ensure claims are received within the contracted amount of time for providers.Single Case Agreements-Process all single case agreement claims received for Dean Health Plan. This includes letters of agreement providing discounted rates over an entire group.All of the above are handled for the following plan types:HMOPOSPPOMedicareMedicaid(including Badgercare and CCHP) Show less



Allstate

• United States
• Real Estate

• Quality Consultant

  • Sep 2011 - Dec 2012

  Review recordings of Claim Service Specialist calls.-Provide feedback and assistance through coaching.-Ensure appropriate coverage discussions are being made and accurate information is beingprovided to customers.-Assisted in running Inquiry Labs that provided additional support to the majority of theoffice.-Track and analyze individual, team and office trends and report to Team Leaders on thetrends.-Perform back-end reviews of Claim Status Workgroup tasks and provide immediate feedbackon areas of opportunity.-Selected as Quality Team MVP in October 2011, July 2012, August 2012 and September 2012.-Nominated for Quality Consultant Hall of Fame August 2012.-Selected as a participant in a User Acceptance Test to determine the functionality of anew process for taking claims. Show less

• Claims Service Specialist

  • Mar 2011 - Sep 2011

  Establish claims based on relevant information provided over the phone by callers.-Provide excellent customer service that leaves the customer completely satisfied.-Discuss coverage available per policy guidelines and explain deductibles.-Contact participants on claims to gather additional relevant information related to theclaim.-Document inbound and outbound contacts with participants on the claim.-Training mentor for new employees in their first 10 weeks of employment with Allstate.-Team representative for Recruiting and Retention committee.-Selected as an Express Yourself winner in August 2011. Show less



American TV

• United States
• Retail
• 100 - 200 Employee

• Sales Professional

  • Aug 2009 - Dec 2010

  Sales Professional -Created positive, memorable, customer experiences resulting from meaningful customer advocacy and follow-up calls. -Reached the advanced level of following the Question and Listening sales process. -Followed a specific skill continuum to advance my abilities as a salesperson. Sales Professional -Created positive, memorable, customer experiences resulting from meaningful customer advocacy and follow-up calls. -Reached the advanced level of following the Question and Listening sales process. -Followed a specific skill continuum to advance my abilities as a salesperson.



Aflac

• Insurance
• 1 - 100 Employee

• Insurance Agent

  • Mar 2009 - Jul 2009

  -Sales prospecting -Direct business sales -Market AFLAC insurance products -Service existing and new payroll accounts -Service existing and new policyholders -Turn gatekeepers into allies by treating them with respect, and compassion. -Help the business decision maker look good in their boss’s eyes by solving a company problem. -If the decision maker is also the owner build credibility and explain how AFLAC can benefit their company. -Sales prospecting -Direct business sales -Market AFLAC insurance products -Service existing and new payroll accounts -Service existing and new policyholders -Turn gatekeepers into allies by treating them with respect, and compassion. -Help the business decision maker look good in their boss’s eyes by solving a company problem. -If the decision maker is also the owner build credibility and explain how AFLAC can benefit their company.



Circuit City

• Technology, Information and Internet
• 700 & Above Employee

• Technology Sales Supervisor

  • May 2004 - Mar 2009

  Supervising staff Training Hiring Coaching Development Creating weekly schedules Ensuring department and store metrics were met Supervising staff Training Hiring Coaching Development Creating weekly schedules Ensuring department and store metrics were met