Experience

Devoted Health

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

• Senior Claims Associate/Program Manager

  • Nov 2018 - Aug 2023

  Waltham, Massachusetts, United States  Collaborate with the engineering team and stakeholders in the development of the user interface. o Worked collaboratively to create Dispute Resolution user interface platform. o Complete routine validation of system configuration of plan benefits, cost share application, fee schedules and applied vendor edits.  Streamline processes through the creation and implementation of workflows to improve accuracy and efficiency within the Claims Team and stakeholders.  Oversight of the… Show more  Collaborate with the engineering team and stakeholders in the development of the user interface. o Worked collaboratively to create Dispute Resolution user interface platform. o Complete routine validation of system configuration of plan benefits, cost share application, fee schedules and applied vendor edits.  Streamline processes through the creation and implementation of workflows to improve accuracy and efficiency within the Claims Team and stakeholders.  Oversight of the dispute resolution process for provider claims: o Managed dispute resolution process, verifying review is completed in accordance with company policies, provider contract terms and applicable product market laws and regulations.  Provider liaison between the Claims Operations, Network, and Providers. o Review complex claims and high-level matters received via the escalation process, completing research and root cause analysis to determine the necessary resolution outcome. o Complete impact analysis to validate and resolve identified process inaccuracies. o Communicate with stakeholders and provide documentation of the issue at hand and resolution outcome.

• Senior Claims Associate

  • Nov 2018 - Aug 2023



NTT DATA Services

• United States
• IT Services and IT Consulting
• 700 & Above Employee

• Business System Analyst

  • Mar 2018 - Oct 2018

  Greater Boston Area  Analyze the current system, identify areas of improvement, and develop solutions to improve the efficiency and effectiveness of the system.  Translates user needs into defined user assessment plans, identifying the specifications used in determining end-user business or technical needs.  Coordinate department meetings with the key stakeholders to address agenda items.  Document interface enhancements between new and legacy systems.  Implement and validate changes through… Show more  Analyze the current system, identify areas of improvement, and develop solutions to improve the efficiency and effectiveness of the system.  Translates user needs into defined user assessment plans, identifying the specifications used in determining end-user business or technical needs.  Coordinate department meetings with the key stakeholders to address agenda items.  Document interface enhancements between new and legacy systems.  Implement and validate changes through program testing. Show less



CeltiCare Health Plan of Massachusetts, Inc.

• Program Coordinator II

  • Sep 2017 - Feb 2018

  Waltham, Massachusetts  Utilize data and analytics to identify members identified as high risk and eligible to participate in company-based Care Management, Behavioral Health, and Disease Management programs.  Initiate intake interviews to engage members in the company's need-based programs, educating members and their families on the importance of compliance with their care plans and the potential consequences.  Develop and maintain relationships with members, their families, and care team to ensure the… Show more  Utilize data and analytics to identify members identified as high risk and eligible to participate in company-based Care Management, Behavioral Health, and Disease Management programs.  Initiate intake interviews to engage members in the company's need-based programs, educating members and their families on the importance of compliance with their care plans and the potential consequences.  Develop and maintain relationships with members, their families, and care team to ensure the members care plan is personalized to the individual needs.  Monitor members' progress and adjust care plans as needed to align with members their goals. Show less



Tufts Health Plan

• United States
• Insurance
• 700 & Above Employee

• Quality Assurance Analyst

  • Aug 2008 - May 2015

  Watertown, Massachusetts Applied auditing criteria in accordance with compliance guidelines, plan’s policies and business procedures, ensuring accuracy of claims processing, group benefits and financial calculations. Implementing quality assurance standards and procedures, conducting tests, analyzing data, and reporting results. Identified risk to plan policies, benefits, procedures and financial calculations. Presented results of audit investigations to the appropriate stakeholders.