Experience

UST HealthProof

• United States
• Hospitals and Health Care
• 100 - 200 Employee

• Manager

  • Jun 2021 - Present

  Pittsburgh, Pennsylvania, United States

• Operation Manager

  • Sep 2018 - Jun 2021

  Sidney, Nebraska Set up BPO healthcare operations in Sidney Nebraska, recruited, trained groom and mentor team leads, claims auditors and claims processors, in charge of the whole operations; managed and communicate with clients on a day to day operational essential as well as short term and medium-term operation strategies. People management: equip team with required resources and skills sets to preform day to day operations, align team expectations with business objectives; team development: identify… Show more Set up BPO healthcare operations in Sidney Nebraska, recruited, trained groom and mentor team leads, claims auditors and claims processors, in charge of the whole operations; managed and communicate with clients on a day to day operational essential as well as short term and medium-term operation strategies. People management: equip team with required resources and skills sets to preform day to day operations, align team expectations with business objectives; team development: identify training needs, coach and mentor team development; customer relationship management and ensuring customer satisfaction consistently. Address all issues both in and outside workplace within the team or across departments that may impact the effectiveness of the company. Responsible of more than a hundred staff members.



Centene Corporation

• United States
• Hospitals and Health Care
• 700 & Above Employee

• Manager Claims

  • Sep 2017 - Mar 2018

  Tyler, Texas Area Managed staff assignment, productivity, and schedules to support key provider data analytics on the department and enterprise level. Be a go between the health plan and claims processing to resolve issues serve as software vendor oversight manager and liaison. Actively participates in pre and post error remediation. Successfully identified root-cause issues in data submissions resulting in time and cost savings related to implementation and troubleshooting. Performer yearly performance… Show more Managed staff assignment, productivity, and schedules to support key provider data analytics on the department and enterprise level. Be a go between the health plan and claims processing to resolve issues serve as software vendor oversight manager and liaison. Actively participates in pre and post error remediation. Successfully identified root-cause issues in data submissions resulting in time and cost savings related to implementation and troubleshooting. Performer yearly performance review for existent staff. Participate in the interviewing process of supervisors and team leads. Processing Medicare and Medicaid plans. Show less



Affinity Health Plan

• United States
• Insurance
• 300 - 400 Employee

• Manager, Provider Data Maintenance

  • Mar 2016 - Mar 2017

  Greater New York City Area Managed staff assignment, productivity, and schedules to support key provider data analytics on the department and enterprise level. Serve as software vendor oversight manager and liaison. Actively participates in user acceptance testing for new requirements and post error remediation. Successfully identified root cause issues in data submissions resulting in time and cost savings related to implementation and troubleshooting.



Healthfirst

• United States
• Hospitals and Health Care
• 700 & Above Employee

• Business Analyst

  • Jan 2015 - Feb 2016

  Greater New York City Area Defines and documents customer business functions and processes. * Create and analyze report utilizing SAS. * Create and maps for recruitment utilizing GeoNetworks and Quest Analytics. * Compile, verify, interpret, analyze and summarize data; identify trends, and communicate results to stakeholders. Provide resource planning and resolution of issues that impede the test effort. * Assist with achieving the appropriate level of quality by working with the Information… Show more Defines and documents customer business functions and processes. * Create and analyze report utilizing SAS. * Create and maps for recruitment utilizing GeoNetworks and Quest Analytics. * Compile, verify, interpret, analyze and summarize data; identify trends, and communicate results to stakeholders. Provide resource planning and resolution of issues that impede the test effort. * Assist with achieving the appropriate level of quality by working with the Information Services Department in resolving important defects and ensuring the appropriate level of testing. * Work directly with all members of the Network Department and other Healthfirst business units as needed to understand project concepts, objectives, and approach. * Provide project and informational updates to management as available and/or assigned. * Collaborate with business units to understand strategic goals and promote an environment conducive to creativity, change, and information exchange. Communicating effectively in written and verbal form. * Conduct data analytics and research pertaining to business needs * Additional duties as assigned Show less



EmblemHealth

• United States
• Insurance
• 700 & Above Employee

• Business Analyst

  • Apr 2014 - Dec 2014

  New York, New York

• Test Analyst

  • Jun 2012 - Apr 2014

  * Perform functional, integration and regression testing. * Test benefits configuration for Medicare 2012. * Analyze professional and facility claims after testing checking for consistency and completeness and provide feedback. * Provide management and QA with a periodical feedback on any issues or findings. * Create test claims scenarios for professional and facility providers. * Test facility and professional providers’ contract implementation. * Coordinate with IS… Show more * Perform functional, integration and regression testing. * Test benefits configuration for Medicare 2012. * Analyze professional and facility claims after testing checking for consistency and completeness and provide feedback. * Provide management and QA with a periodical feedback on any issues or findings. * Create test claims scenarios for professional and facility providers. * Test facility and professional providers’ contract implementation. * Coordinate with IS (informational System) to discuss configuration findings based on test outcome. * Write detailed test plans * Serves as the liaison with the seniors and managers in the Claims Operations concerning the business requirements, planning, testing and communication of projects * Write detailed test plans Review the Business Requirements for proposed implementations in the Claims Department. * Knowledge of NCQA, JCAHO, CMS, CAQH and CORE accreditation.. * Test EDI and Paper submissions lifecycle claims



DBI Staffing

• United States
• Staffing and Recruiting
• 1 - 100 Employee

• UAT Consultant

  • Oct 2011 - Jun 2012

  Perform functional, integration and regression testing. * Test benefits configuration for Medicare 2012. * Analyze professional and facility claims after testing checking for consistency and completeness and provide feedback. * Provide management and QA with a periodical feedback on any issues or findings. * Create test claims scenarios for professional and facility providers. * Test facility and professional providers’ contract implementation. * Coordinate with IS… Show more Perform functional, integration and regression testing. * Test benefits configuration for Medicare 2012. * Analyze professional and facility claims after testing checking for consistency and completeness and provide feedback. * Provide management and QA with a periodical feedback on any issues or findings. * Create test claims scenarios for professional and facility providers. * Test facility and professional providers’ contract implementation. * Coordinate with IS (informational System) to discuss configuration findings based on test outcome Show less



Healthplus New York

• Claims Supervisor

  • Oct 2010 - Jun 2011

  Brooklyn, New York • Provided day-to-day direct supervision and oversight to appropriate business staff of forty (40). • Monitored productivity (identifying trends and issues). • Provided monthly and weekly inventory and production report to senior management. • Reviewed daily inventory and provide analysis to staff of aged claims. • Completed timecard biweekly to payroll. • Daily staff production analysis. • Performed reconciliation of payments to providers and prepared pertinent paperwork and… Show more • Provided day-to-day direct supervision and oversight to appropriate business staff of forty (40). • Monitored productivity (identifying trends and issues). • Provided monthly and weekly inventory and production report to senior management. • Reviewed daily inventory and provide analysis to staff of aged claims. • Completed timecard biweekly to payroll. • Daily staff production analysis. • Performed reconciliation of payments to providers and prepared pertinent paperwork and • correspondence to resolve discrepancies. • Provided biweekly attendance and late analysis to director. • Business analysis, new benefits and configurations testing. • Interviewed potential candidates, evaluated staff performance and recommended hiring, promotions, and terminations, as appropriate. • Assisted with the claims department preparation for DOH and DOI audits. • Prepared, schedule and approved time off request. • Provided analyzed pond reports to other department for claims resolution. • Analyzed claims denial and provided feedback to management and providers Show less



VNS Health

• United States
• Hospitals and Health Care
• 700 & Above Employee

• Claims Analyst/Auditor

  • Feb 2008 - Jun 2010

  Greater New York City Area • Analyzed audit results to recommend system or procedural changes to increase claim accuracy • and/or identify opportunities for workflow enhancements. • Provided feedback or suggestions to enhance current processes and/or systems. • Assisted in compliance reviews of internal and third party administrators claims processing • policies and procedures. • Performed reconciliation of payments to providers and prepared pertinent paperwork and correspondence to resolve… Show more • Analyzed audit results to recommend system or procedural changes to increase claim accuracy • and/or identify opportunities for workflow enhancements. • Provided feedback or suggestions to enhance current processes and/or systems. • Assisted in compliance reviews of internal and third party administrators claims processing • policies and procedures. • Performed reconciliation of payments to providers and prepared pertinent paperwork and correspondence to resolve discrepancies. • Performed business analysis, new benefits analysis and configurations testing. • Reviewed, adjusted and updated in accordance with CMS policies/guidelines. • Responsible for finding errors and trends that would of cost the organization millions of dollars in claims paid incorrectly or not paid. Responsible for the auditing functions of VNS CHOICE claims. • Resolved provider disputes and complaints received from providers, members and internal departments to facilitate adherence to Medicare and Medicaid regulations. • Collaborated with other Health plan departments to ensure claims are processed in accordance • with established guideline and/or policies and procedures.

• Supervisor of Member Services

  • Feb 2006 - Feb 2008

  Greater New York City Area • Provided day-to-day direct supervision and oversight to appropriate business staff. • Performed monthly audit to calls and identify trends of the Automatic Calls distribution. • Responsible for coordinating the daily work schedule of assigned staff to ensure there is • adequate coverage to attend to member needs. • Monitored customer service activities and performance to assure that standards are met or exceeded by ensuring that the day-to-day policies and standards of the program… Show more • Provided day-to-day direct supervision and oversight to appropriate business staff. • Performed monthly audit to calls and identify trends of the Automatic Calls distribution. • Responsible for coordinating the daily work schedule of assigned staff to ensure there is • adequate coverage to attend to member needs. • Monitored customer service activities and performance to assure that standards are met or exceeded by ensuring that the day-to-day policies and standards of the program are upheld. • Interviewed potential candidates, evaluates staff performance and recommends hiring, • promotions, salary actions, and terminations, as appropriate.



Metropolitan Jewish Health Service\Elderplan,

• Claims Analyst/Auditor

  • May 2004 - Feb 2006

  Greater New York City Area • Audited examiners production once a week at 30% of daily production. • Provided reporting status of examiners claims processing to managers/supervisors. • Ensured claims are processed in accordance with provider contract, member benefits, and authorization requirements, and regulatory requirements. • Carefully evaluated claims to determine if they are processed within the specifics guidelines in • accordance with policies and procedures.



HIP Health Plan Of New York

• United States
• Hospitals and Health Care
• 1 - 100 Employee

• Claims Facility Trainer - HR/Learning & Development

  • Jan 2003 - Apr 2004

  Greater New York City Area • Collected and processed training feedback using evaluation techniques. Modify program • content when needed. • Designed and developed claims and product based training programs and activities, determining • appropriate program content and prepare training materials. • Delivered facility claims based training and development modules and programs, using • appropriate techniques and strategies. • Trained incoming and current staff in claims processing. • Provided one and one or… Show more • Collected and processed training feedback using evaluation techniques. Modify program • content when needed. • Designed and developed claims and product based training programs and activities, determining • appropriate program content and prepare training materials. • Delivered facility claims based training and development modules and programs, using • appropriate techniques and strategies. • Trained incoming and current staff in claims processing. • Provided one and one or group tutoring Show less



MONTEFIORE MEDICAL CENTER

• United States
• Hospitals and Health Care
• 700 & Above Employee

• Senior Medical Audit Analyst: (Coding Supervisor)

  • Jul 2001 - May 2002

  Greater New York City Area Health Information Management Department • Managed the operation of the coding unit, maintained the workflows of the unit, while ensuring compliance with established procedures. • Monitored productivity (identifying trends and issues). • Ensured timely processing of Smart, and HROI (Quality tools). • Followed up and expedited final coding on charts placed on bill hold. • Managed the coding backlog report; provided a status of discharges for each month. • Performed daily… Show more Health Information Management Department • Managed the operation of the coding unit, maintained the workflows of the unit, while ensuring compliance with established procedures. • Monitored productivity (identifying trends and issues). • Ensured timely processing of Smart, and HROI (Quality tools). • Followed up and expedited final coding on charts placed on bill hold. • Managed the coding backlog report; provided a status of discharges for each month. • Performed daily productivity monitoring for all coders (Moses Div., Einstein Div., and • independent consultants). • Ensured complete and accurate data for reporting to the Department of Health. Show less



Horizon Blue Cross and Blue Shield of NJ

• Training /Quality Analyst

  • Sep 1999 - May 2001

  Newark, New Jersey • Conducted job-related technical programs for operations personnel to ensure conformance and • quality of claim processing and service procedures. • Developed and revised training programs, materials to keep information current, and applicable specific job tasks. • Worked with Operations, as a training liaison to identify and support training needs. • Performed quality reviews of claims including the assessment of coordination of benefits (COB) rules • Identified and documented… Show more • Conducted job-related technical programs for operations personnel to ensure conformance and • quality of claim processing and service procedures. • Developed and revised training programs, materials to keep information current, and applicable specific job tasks. • Worked with Operations, as a training liaison to identify and support training needs. • Performed quality reviews of claims including the assessment of coordination of benefits (COB) rules • Identified and documented processing deficiencies. Provided recommendations for improvement. Show less



First Options Health Plan

• Claims Trainer

  • Sep 1996 - Sep 1999

  Neptune, New Jersey  Conduct needs analysis for the claims department as designated.  Maintain practical and comprehensive claims Manual.  Trained staff on claims payment system, policy, and procedure.  Responsible for preparation of the Training Room, “dummy” claims, and syllabus for training class.  Prepare schedule for training and auditing. Assist with benefit interpretation questions.  Created Workshop and Seminars related to Policies and Procedures updates.