Lead Analyst with over 12 years of successful experience in the health care industry. Well-versed in due diligence, business trends and analyses. Prepares models, forecasts trends and gives presentations. Detailed in data analyses and reporting for audits, trend determination and financial planning.
Work History
07/2011 to Current
Corporate Audit- CIGNA, Lead AnalystState Of North Carolina – Salisbury, NC,
Supervised and developed associates and oversaw auditing activities across operational, personnel utilization and excessive billing areas.
Managed high claim volume and investigations
Project lead
Followed up on reviews to assess and report on completion or progress of corrective actions.
Analyzed trends over monthly, quarterly and annual basis to investigate fluctuations/trends.
Investigated and addressed incorrect billing trends
Developed and implemented corrective actions to bring business areas in line with standards.
Prepared working papers, reports and supporting documentation for audit findings.
Complied with federal, state and local requirements.
Achieved cost savings by discovering opportunities to amend provider contract agreement.
Complied with established internal procedures by examining reports, processes, and documentation.
Worked with legal entities to come to settlement agreements.
12/2008 to 07/2011
Claims Manager-LTDGroup Insurance-CIGNA – City, STATE,
Providing expert knowledge and building positive, trusting relationship to support clients during challenging times.
Determined proper course of action for claims processing.
Identified insurance coverage limitations with thorough examinations of claims documentation and related records.
Collected and tracked evidence in support of legal processes.
Reviewed questionable claims by conducting agent and claimant interviews to correct omissions and errors.
Handled claims consistent with client and corporate policies, procedures, best practices and regulations.
Reviewed medical treatment records to determine extent of fraud
Worked with Federal Agency, and local law enforcement.
01/2006 to 06/2007
Medical Claims RepresentativeProgressive Auto Insurance – City, STATE,
Followed up on potentially fraudulent claims initiated by claims representatives.
Managed large volume of medical claims on daily basis.
Paid or denied medical claims based upon established claims processing criteria.
Prepared insurance claim forms or related documents and reviewed for completeness.
Communicated effectively with staff, including members of operations, finance and clinical departments.
Reviewed medical records and conducted medical reviews.
Interviewed clients to confirm facts and liability .
Worked with internal employees and managers to conduct audit reviews.
2004 to 2005
Child Care ConsultantAIU3 – City, STATE,
Meet with the business owners of child care facilities, or teachers of head start facilities to manage their daily operations.
Developing trainings for business owners, and confirming compliance trainings to maintain certificates.
Maintaining a partnership with business owners on their continuing education needs.
Organizing meetings to resolve compliance issues within the business.
One on one meetings with management, and business owners.
Audits completed pertaining to educational needs, and requirements by the state.
Developing treatment plans.
Responsible for communication with parents, and teachers on goal achievement.
Education
Expected in 05/2021
MBA: Healthcare Management Waynesburg University - Waynesburg, PA GPA:
Expected in 05/2004
Bachelor of Arts: Liberal Arts, Minor Education Clarion University of Pennsylvania - Clarion, PA GPA:
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