Experience

ClaimInformatics, Ltd.

• Director Of Analytics

  • Jun 2018 - Present



ClaimInformatics, LLC

• Director of Analytics

  • Jun 2018 - Present

  At ClaimInformatics, we are dedicated to discovering and recovering improper payments on behalf of employers and administrators. We have designed a state-of-the-art, highly secure, HIPAA Compliant system that provides new levels of accuracy and transparency for improved payment integrity. This new platform has been designed to provide a granular forensic review of all healthcare claim transactions. We handle recovery and reconciliation of improper payments as well as detection of fraud, waste and abuse. Our process incorporates an end-to-end solution with corrective action plans. We have a continuous monitoring cycle and we deploy code auditing controls for pre-payment applications that favors the most effective configuration for your specific payer. Our method of “auditing an employer’s group health plan”, has a two-pronged approach:• Post-Payment services (review 100% of all claim payment transactions), and • Pre-Payment services (fix the problem) to improve payment accuracy and limit future recoupment efforts. Our clients will gain unprecedented insights into their true cost drivers through our ClaimInformatics team of industry experts and leading technology.



BMI Audit Services, LLC

• Senior Claims Auditor & Analytics Coordinator

  • Nov 2015 - May 2018



ClaimReturn LLC

• United States
• Data Infrastructure and Analytics
• 1 - 100 Employee

• Director of Analytics

  • Dec 2012 - Oct 2015

  My responsibilities included:• Collaborate with internal and external clients and data providers to create state of the art predictive analytics and advanced statistical techniques.• Accounted for the overall management of analytic edit projects; including profitability, timeliness, quality and client value.• Managed multiple resources and projects concurrently to ensure successful completion of analytic projects My responsibilities included:• Collaborate with internal and external clients and data providers to create state of the art predictive analytics and advanced statistical techniques.• Accounted for the overall management of analytic edit projects; including profitability, timeliness, quality and client value.• Managed multiple resources and projects concurrently to ensure successful completion of analytic projects



Thomson Reuters (now known as Truven Health)

• Sr. Consultant Audit & Compliance

  • Jan 2011 - Apr 2012

  My responsibilities included providing all coding (CPT/HCPCS, ICD-9, etc.) for editing logic, the performance of pre-implementation audits, targeted/focused and random medical/eligibility, excess loss audits for self-funded employers, subsequent planning for recovery efforts and the identification and implementation of system and process improvement opportunities for clients and Third Party Administrators (TPAs) alike; resulting in minimization of future errors. I was also tasked with the completion of On-site Operational & Administrative reviews.



Self Employed; Consulting & Auditing

• Independent Medical Claims Consultant/Auditor Independent Consultant & Auditor

  • Jan 2008 - Jan 2011

  Performed pre-implementation, focused, and random medical claim audits (including eligibility, provider contracts, standard medical industry practices to name a few). Prepared analyses/reports based on audit results, including recommendations for corrective action. Acted as a resource on coding updates/issues (CPT, ICD-9, DRG, etc.). Performed pre-implementation, focused, and random medical claim audits (including eligibility, provider contracts, standard medical industry practices to name a few). Prepared analyses/reports based on audit results, including recommendations for corrective action. Acted as a resource on coding updates/issues (CPT, ICD-9, DRG, etc.).



HealthCare Data Managment (HDM)

• Senior Audit Manager

  • Jan 2000 - Apr 2008

  • Identified process improvement opportunities for clients and Third Party Administrators (TPA) to minimize future errors.• Performed targeted/focused and random audits for clients using material gathered on benefits, eligibility, claims processes, provider contracts, and plan designs.• Recommended actions to improve client satisfaction with Third Party Administrators.• Worked with clients and TPAs to plan recovery of overpaid claims.• Identified operational and administrative performance issues at the payer site.