Experience

Anthem Blue Cross Health Insurance

• United States
• Insurance
• 1 - 100 Employee

• HEDIS Coordinator

  • Mar 2020 - Present

  St. Louis City County, Missouri, United States



Centene Corporation

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

• Project Manager / Business Analyst

  • Dec 2016 - Aug 2019

  Clayton, Missouri Primary contact for 13 health plans with Medicare, Medicaid and Marketplace lines of business for support of adoption and implementation of new payment and clinical policies and post pay programs to maximize savings. Working with senior leadership to identify and break through barriers for implementation. Perform demonstration of savings potential, including identification of missed opportunities for savings. • Primary contact for local health plans regarding existing payment and clinical… Show more Primary contact for 13 health plans with Medicare, Medicaid and Marketplace lines of business for support of adoption and implementation of new payment and clinical policies and post pay programs to maximize savings. Working with senior leadership to identify and break through barriers for implementation. Perform demonstration of savings potential, including identification of missed opportunities for savings. • Primary contact for local health plans regarding existing payment and clinical policies • Present new payment and clinical policies and post pay programs to local health plans for opportunities in cost savings. • Serve as the subject matter expert on proposed and existing payment and clinical policies implemented through payment edits and post pay programs available to health plans for recovery opportunities. • Work with health plans to identify barriers to implement/maintain policies and post pay programs, seek to identify alternative methods of implementation to maximize savings potential. Show less



UnitedHealth Group

• Hospitals and Health Care
• 700 & Above Employee

• HEDIS Data Collection Specialist

  • Oct 2015 - Jan 2016

  Maryland Heights, MO • Trained and managed staff regarding HEDIS supplemental data, HEDIS guidelines, and software used to store data. • Contacted physician offices to set appointments for visits to office to review charts for potential supplemental data. • Reviewed scorecard data to identify physician and patients that displayed potential for significant improvement in Star rating and performed education for staff and physicians.



Essence Healthcare

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

• Provider Metric Account Manager

  • Mar 2014 - Jun 2015

  13900 Riverport Drive, Maryland Heights, MO 63043 Responsible for working with cross-functional teams involved in provider metrics, maintaining working relationships with network providers; and assessment of provider training needs and the coordination of training programs with Essence staff. • Responsible for managing provider measurements and maintenance of CMS Star related and quality metrics through management of provider groups and projects. • Establish and maintain ongoing relationships with the physician and business leadership of… Show more Responsible for working with cross-functional teams involved in provider metrics, maintaining working relationships with network providers; and assessment of provider training needs and the coordination of training programs with Essence staff. • Responsible for managing provider measurements and maintenance of CMS Star related and quality metrics through management of provider groups and projects. • Establish and maintain ongoing relationships with the physician and business leadership of Essence network of physicians. • Monitor provider contract performance to ensure financial, operational and strategic objectives are satisfied. • Serve as the primary point of contact for assigned provider office staff in answering questions about provider analytics reporting issues, interpretations, resolve any issues that may arise related to provider metrics. • Provide in-office training and orientation for new and existing providers regarding measurements and metrics. • Assist department leadership with development of provider-specific metrics and participate and provide support to the department leadership for contract negotiations of provider metrics. Show less



Access2Care

• Client Service Representative

  • Feb 2014 - Mar 2014

  Greater St. Louis Area

• Client Account Manager

  • Jan 2014 - Mar 2014

  2500 Abbott Pl. St. Louis, MO 63143 Responsible for establishing and maintaining relationships with external clients to provide statistical data, resolve complaints, and to ensure overall satisfaction. • Primary contact for external clients for reporting of monthly statistics with a focus on complaint resolution. • Responsible for process improvements regarding reporting processes and data management. • Assisted with support of expansion of services into new markets for the Medicaid product.



UnitedHealth Group

• Hospitals and Health Care
• 700 & Above Employee

• Business Analyst

  • Mar 2011 - Aug 2013

  Maryland Heights, MO Liaison between National Stars Improvement Team, United Health Network (UHN) and Medicare and Retirement (M&R) executive staff. • Responsible for receipt of Stars Improvement reporting from corporate team, communicating content of reports and coordinating action items with the Central Region Stars Improvement Vice President and seven Regional Vice Presidents. • Assisted with research, development, deployment, education and analytics of the Stars Improvement Program (SIP) to improve the… Show more Liaison between National Stars Improvement Team, United Health Network (UHN) and Medicare and Retirement (M&R) executive staff. • Responsible for receipt of Stars Improvement reporting from corporate team, communicating content of reports and coordinating action items with the Central Region Stars Improvement Vice President and seven Regional Vice Presidents. • Assisted with research, development, deployment, education and analytics of the Stars Improvement Program (SIP) to improve the overall rating of Medicare contract performance. Program was successfully deployed in 13 Central Region markets. • Responsible for documentation and tracking of contract requests to UHN and performance against requests for both contract remediation and provider development. • Implementation of significant process improvements and communication within UHN and M&R staff.

• Senior Network Pricing Consultant for Government Programs

  • Oct 2005 - Mar 2011

  Maryland Heights, MO Responsible for communication, education and administration of overall Medicare and Medicaid specific reimbursement policies and procedures to market specific personnel. • Support local Healthcare Economics personnel regarding annual Market Target setting processes. • Developed and maintained annual Medicare equivalency analytics nationally across multiple claims processing platforms and data warehouses. • Assisted with development of Medicare and Medicaid equivalency analytics using… Show more Responsible for communication, education and administration of overall Medicare and Medicaid specific reimbursement policies and procedures to market specific personnel. • Support local Healthcare Economics personnel regarding annual Market Target setting processes. • Developed and maintained annual Medicare equivalency analytics nationally across multiple claims processing platforms and data warehouses. • Assisted with development of Medicare and Medicaid equivalency analytics using HPM (Hospital Pricing Model). • Responsible for annual tiering of provider network for Medicare and Medicaid. • Responsible for developing processes to reconcile contracts with reimbursement methodology specific to Medicare reimbursement for national provider systems. • Performed provider specific analytics to determine financial impact of proposed contract changes

• Medicare Senior Financial Analyst

  • Nov 2002 - Oct 2005

  Maryland Heights, MO Responsible for daily financial analytics to support executive staff for evaluation of potential financial improvement. • Developed and maintained database to track monthly utilization metrics by facility and primary care physicians used for executive reporting and daily analytics. • Supported monthly process to measure primary care groups gain share performance and reconcile payments. • Responsible for detailed analytics to research HCTA (Health Cost Trend Analysis) reporting for… Show more Responsible for daily financial analytics to support executive staff for evaluation of potential financial improvement. • Developed and maintained database to track monthly utilization metrics by facility and primary care physicians used for executive reporting and daily analytics. • Supported monthly process to measure primary care groups gain share performance and reconcile payments. • Responsible for detailed analytics to research HCTA (Health Cost Trend Analysis) reporting for purpose of targeting reducing high cost trends (received Standing Ovations Award). • Performed key analytics to support initiative of moving providers from per visit logic to Medicare’s OPPS logic.

• Senior Business Analyst

  • Jun 2000 - Nov 2002

  Maryland, MO Primary contact for end users requesting data and interpreting requests to determine user’s needs. • Responsible for developing programs to retrieve and manipulate data using Cognos tools for simple requests, developing specifications while working with SAS programmer for more complicated requests, performing quality checks to ensure the results met end user’s needs. • Assisted with developing standard reporting for health plans as they migrate from prior databases to current… Show more Primary contact for end users requesting data and interpreting requests to determine user’s needs. • Responsible for developing programs to retrieve and manipulate data using Cognos tools for simple requests, developing specifications while working with SAS programmer for more complicated requests, performing quality checks to ensure the results met end user’s needs. • Assisted with developing standard reporting for health plans as they migrate from prior databases to current databases. • Assisted with migration of standard reporting from sun-setting data warehouse to future comprehensive data warehouse. • Assisted with the design development of HPDM (Health Plan Data Mart), currently know as UGAP (UnitedHealth Group Analytics Platform), and performed extensive QA and development of summarized reporting for executive levels.



Medi

• Medicare Claims Liaison

  • Jun 1998 - Jun 2000

  Maryland Heights, MO Key contact between the Health Plan and the claims processing site. Responsible for developing and maintaining P&P’s for the claims processing site, creating and maintaining claim edit reviews. • Ran reports using Cognos tools as needed to assist in research of trends and claims processing problems. • Performed research for providers with extensive claims problems and implemented processes to resolve re-occurring problems as well as performed analytics to assist with settlements.



UnitedHealth Group

• Hospitals and Health Care
• 700 & Above Employee

• Medicare Provider Service Representative

  • Apr 1997 - Jun 1998

  Maryland Heights, MO • Received incoming calls from providers regarding eligibility, benefit, and claim status inquiries. • Researched claim processing errors and requested adjustments and/or reprocessing of claims where appropriate.