Driven, energetic and hardworking Business Configuration Analyst with over twenty eight years in the healthcare insurance industry. Experience in claims processing, training and auditing, lead customer service representative, provider relations and contract building. Well-qualified in all lines of business from TPA, PPO, POS, HMO, Medicare and Medicaid. Working knowledge of CPT, ICD9, DRG, HCFA and UB92 coding.
Healthcare industry best practices, HIPAA compliance, HMO, indemnity, commercial, Medicare and Medicaid lines of business, policy development and implementation, quality assurance standards, Microsoft Excel, Microsoft Word, contract building, claims review, extensive Xcelys knowledge, team player
Business Configuration Analyst04/2009 to CurrentKaiser PermanenteEnglewood, COConducts functions of the Business Configuration
administration team which includes design, development and testing activities
of all components with in the departmental scope of Business
Configuration. Executes and delivers the
collection, interpretation, analysis, and organization of information and data
necessary to deliver on established organizational and departmental goals
within the scope of responsibility.
Participates in cross functional team focused on performance
improvements needed in HPSA operations.
Executes on activities to integrate knowledge of business drivers,
operations, information technology, change management, strategic and tactical
planning in support of key business initiatives. Developed DLP and
workflow for provider contracts within Xcelys.
Claims Trainer11/2008 to 05/2009Kaiser PermanenteEnglewood, COTrained employees to understand and learn the Xcelys claims processing system. Developed all training materials, in both hard and soft copies, organized and presented hands on activities, drafted job aids for the claims adjudicator department
Claims Examiner/Senior Claims Consultant09/2005 to 10/2008Employee Benefit Management Services/Mountain States AdministrationAurora, COProcess medical, dental and vision insurance claims
adhering to contractual language and
negotiations. Review medical records to determine medical necessity
based on standards of care. Respond to customer inquiries regarding claim status
and verification of contractual language.
Customer Service Representative12/2004 to 03/2005Admin OneTulsa, OKResponsible for answering a high volume of calls from
enrollees and providers regarding plan
benefits, HRA accounts, and
claim payment inquiries. Analyzed and resolved issues or concerns regarding
claims processing.
Claims Trainer/Auditor07/2004 to 12/2004Community Care HMO of OklahomaTulsa, OKDeveloped and maintained an aggressive training program
for new and established employees in a
department of thirty associates. Analyzed documentation to determine where additional
training was needed. Provide answers to all claims related questions from
all associates. Performed auditing of claims auditors. Conducted software quality testing.
Provider Relations Representative08/2001 to 02/2004Schaller Anderson of Oklahoma LLCTulsa, OKResponsible for developing, contracting, maintaining,
and strengthening the provider network in
accordance with the plans' requirements. Provided onsite training and education to physicians,
facilities, and office personnel. Worked closely with providers to resolve claim and
contractual issues. Responsible for monitoring provider and vendor
compliance on access, quality and member
satisfaction. Interact with other departments to resolve problems for
physicians and facilities. Prepare monthly reports regarding provider network,
specified needs, and trends in complaints,
denials and utilization monitoring. Researched and negotiated financial analysis for
contractual evaluation. Created correspondence to disseminate information and
address specific issues and problems.
Reciprocity Claims Specialist05/2001 to 06/2001Blue Cross Blue Shield of OklahomaTulsa, OKAdministered benefits for multiple lines of business in
a production environment. Closely monitored performance group claims to meet
contractual requirements, minimizing
penalties imposed upon plan. Maintained less than 5% in non-conformance. Undertook special projects to assist management. Accountable for claims adjustments, problem analysis
and communication with other plans
regarding claims issues and payments.
Claims Trainer/Auditor02/2008 to 05/2001Blue Cross Blue Shield of OklahomaTulsa, OKTrained associates to achieve effective and efficient
claims processing. Maintained and reported daily audits and performance
audits. Implemented and evaluated documentation to help provide
accurate, current claims adjudication
guidelines. Addressed associates' inquiries.
Customer Service Representative08/1996 to 02/1998Blue Cross Blue Shield of OklahomaTulsa, OKResponsible for answering high call volume phone lines
to provide assistance for enrollees and
providers. Addressed benefit coverage, claims payment inquiries
and provider information. Analyzed and resolved issues or concerns regarding
provider network or claims processing. Responded to written inquiries submitted by providers
and members. Promoted to group leader representative based on the
ability to resolve complex and problematic
issues. Dealt with group's Human Resource representative to
maintain customer service satisfaction.
Claims Examiner01/1995 to 08/1996Blue Cross Blue Shield of OklahomaTulsa, OKResponsible for claims adjudication for multiple lines
of business in a production environment.
Chiropractic Assistant/Office Manager06/1989 to 06/1994Dr. Howard J Boos, D.C.Tulsa, OKResponsible for the smooth and successful operation of
the physician's office. Accountable for taking and developing X-Rays. Maintained medical records including but not limited to
insurance billing. Managed both accounts receivable and accounts payable. Interacted with insurance companies, attorneys, and
patients. Trained new employees. Oversaw front office including scheduling appointments. Produced daily reports of financial analysis. Attended multiple job related seminars.
