Software Engineer

• Jul 2023 - Present

Application Developer

• Aug 2022 - Jul 2023

Reviews, analyzes, modifies, creates, debugs, and tests applications using modern development methodologies and tools. Participated in design and application architecture discussions. * Responsible for the process, lifecycle, and creation of the software to assist users in completing a computer task or program. * Implements code and documents all system changed based on assignments. * follows department coding and user interface guidelines. * provides code review,… Show more Reviews, analyzes, modifies, creates, debugs, and tests applications using modern development methodologies and tools. Participated in design and application architecture discussions. * Responsible for the process, lifecycle, and creation of the software to assist users in completing a computer task or program. * Implements code and documents all system changed based on assignments. * follows department coding and user interface guidelines. * provides code review, testing, debugging, technical documentation, general testing instructions, assistance in go-live planning, assistance in go-live moves, and post-live support. * Communicates any and all progress, roadblocks, and issues to the team and management in a timely manner

Data and Reporting Analyst - Intermediate

• Nov 2021 - Aug 2022

​- Performs complex data analysis in support of ad-hoc and standing customer requests - Uses and supports database applications and analytical tools: evaluates data quality, applications, functions and produces outputs. - Creates and generates reports related to network composition or expansion through various programs and direct links to core databases. - Analyzes and illustrates the network accessibility of provider networks to a customer’s employee or member population, as well as… Show more ​- Performs complex data analysis in support of ad-hoc and standing customer requests - Uses and supports database applications and analytical tools: evaluates data quality, applications, functions and produces outputs. - Creates and generates reports related to network composition or expansion through various programs and direct links to core databases. - Analyzes and illustrates the network accessibility of provider networks to a customer’s employee or member population, as well as identify disruption risk in evaluating RFP’s for both new or existing business. - Interfaces with external vendors for federal and state regulatory reporting. - Applies business experience and analytical skills to define project scope and identify trends. - Runs existing department reports, including provider data reports and management reports and designs and develops new reports as required by management. - Coordinates internal and external education regarding process improvements, including recommended policy improvements and configuration changes. - Develops and maintains Department workflows as required. - Provides technical, analytical and business guidance to other team members and departments within the Health Plan.

Credentialing Coordinator

• Jan 2019 - Nov 2021

-Updates, maintains and organizes accurate, up-to-date information in Provider Network Management's data information systems and/or applications that contain critical credentialing, contractual, demographic and related provider data. Coordinates associated process flow to ensure that informational updates applied within such areas are timely communicated to applicable staff. -Enters data from provider applications or delegate lists. Scans and attaches documentation, license records, etc… Show more -Updates, maintains and organizes accurate, up-to-date information in Provider Network Management's data information systems and/or applications that contain critical credentialing, contractual, demographic and related provider data. Coordinates associated process flow to ensure that informational updates applied within such areas are timely communicated to applicable staff. -Enters data from provider applications or delegate lists. Scans and attaches documentation, license records, etc. and interprets or adapts data and images to conform to defined data fields. Maintains established level of data accuracy -Runs data reports to ensure the accuracy of basic database elements and configurations such as provider profiles, pending provider lists and expired credentials. Provides data to internal and external requesters as necessary to support credentialing processes. -Utilizes DBMS data audit reports to ensure the accuracy of Health Plan Provider data. Provides data updates to the system to ensure data completeness, consistency and synchronization with other Health Plan data sets -Conducts formal testing procedures and applicable documentation in response to data system/application implementation, upgrade, migration, disaster recovery procedures or other purpose(s), as needed. -Develops and maintains routine and standard ad hoc reports, as needed, associated with the retrieval of data and information from PNM’s data information systems and other Health Plan data sources or applications. Prepares reports in response to internal and/or external requests for data for purposes of audit, regulatory reporting or to support business operational needs. Works cooperatively with Provider Data Analyst to assess reporting design to ensure accurate data retrieval, reliability, consistency and completeness. -Maintains knowledge of Health Plan data sets and applications, including but not limited to DBMS and the Enterprise Data Warehouse.

Claims Specialist

• Jul 2015 - Jan 2019

Provides guidance to CSR I and CSR II (including Contact Center) in complex claims analysis. - Provides support and mentoring for newly hired Claim staff. - Manages a complex claims caseload while adhering to production and quality standards. -Organizes and distributes CRRF work to staff members. -Performs root cause investigations of complex claims, benefits, claim edit, etc…issues. -Determines if services received are covered benefits as applicable by line of business and… Show more Provides guidance to CSR I and CSR II (including Contact Center) in complex claims analysis. - Provides support and mentoring for newly hired Claim staff. - Manages a complex claims caseload while adhering to production and quality standards. -Organizes and distributes CRRF work to staff members. -Performs root cause investigations of complex claims, benefits, claim edit, etc…issues. -Determines if services received are covered benefits as applicable by line of business and product design. -Reviews suspended claims for resolution by applying current policies, procedures and benefits applicable to specific GHP products. -Reviews and maintains a working understanding of all claims processing and procedures for current criteria for claims resolution. - Revises all claims processing policies and resource documents. -Assists Team Leader with special projects related to claims adjudication and claims adjustments. -Provides team building resources to assist in directing peers to proper claims resolution policies and procedures in order to assist members and providers. -Develops and maintains awareness and working knowledge of Amisys Advanced, IDM Tower, Burgess Reimbursement Software, GHP Encyclopedia systems, GHPs external website and Abovehealth. -Performs duties to support the Health Plan to provide member health care, member and provider satisfaction. -Troubleshoots system errors and coordinates with the appropriate internal departments for resolution. -Maintains knowledge of all Health Plan products in order to provide the highest level of customer service and support to members, providers and employers. - Researches claim issues from providers and identifies specific criteria for reconsideration for payment. - Maintains member/provider confidence by helping to protect the confidentiality of information coming into and being disseminated out of the department according to HIPAA guidelines.

GSS-1

• Dec 2013 - Jun 2015

Monitor resident's behavior - Ensure a safe, harassment free atmosphere conductive to recovery - Perform building checks for cleanliness and safety - incident reporting to include writing incident reports, reporting immediately to supervisor or program manager and following state guidelines - Monitor residents while they take their prescribed medication, report all medication monitoring issues - Facilitate group activities Monitor resident's behavior - Ensure a safe, harassment free atmosphere conductive to recovery - Perform building checks for cleanliness and safety - incident reporting to include writing incident reports, reporting immediately to supervisor or program manager and following state guidelines - Monitor residents while they take their prescribed medication, report all medication monitoring issues - Facilitate group activities

Bar Manager

• Mar 2008 - Dec 2013

- Recruit, interview, hire and train bar staff - interact with customers to develop loyalty and handle customer concerns - Ensure all licenses are current -Ensure all staff is following safety regulations - Create employee schedules - Set and maintain standards for safe food handling - Negotiate with vendors, order supplies, and manage inventories and budgets. - Recruit, interview, hire and train bar staff - interact with customers to develop loyalty and handle customer concerns - Ensure all licenses are current -Ensure all staff is following safety regulations - Create employee schedules - Set and maintain standards for safe food handling - Negotiate with vendors, order supplies, and manage inventories and budgets.