Fee Schedule Analyst Resume Example Care 1St Health Plan

FEE SCHEDULE ANALYST

Professional Background

Health insurance professional with a cumulative 20 years' experience with configuration, adjusting, processing, investigating, interpreting contracts and interpreting fee schedules for health insurance claims.

Skill Highlights

Claims Examiner
Claims Adjuster
Contracts Analyst
Benefit Configurations

Customer Service
Benefits Testing
Benefit Administration
System Implementation

Professional Experience

08/2015

Fee Schedule AnalystCare 1st Health Plan - Phoenix, AZ

Responsible for implementation and maintenance of all updates to fee schedules in MHC system.
Ensures accuracy of all fee schedule set up in MHC.
Performs system testing of fee schedules to validate that setup produces desired results Conducts thorough follow-up and effective resolution and communication in response to other departments.
Works closely and collaboratively with other departments.
Effective understanding of the organizations goals and objectives.
Performs other duties, assignments and responsibilities as assigned or required.

09/2013 to 07/2015

Project AnalystXerox, Total Benefits Outsourcing - Phoenix, AZ

Synthesized with the Human Resources department to developed processes related to compensation and benefits.
Provided avenues for ensuring quality of employee benefits management.
Administered and ensured timely enrollment of employee benefits plan and liaison and tracked with vendors for accurate coverage.
Managed online benefit system and troubleshoot errors to ensure data integrity.
Processed and review monthly insurance bills for accuracy and payment advances.
Resolved discrepancies and employee health and welfare complaints and escalations.
Interfaced as a key resource to resolve issues on eligibility, claims and termination.
Responded to associate queries on benefits and insurance claims by troubleshooting problems and interfacing between vendors and employees.
Handled the day-to-day work to service client needs, coordinated the client team and respond to client inquiries * Managed client projects and provide updates to Account Manager and Implementation Manager.
Assisted Implementation Manager and Client Manager with new plan implementation processes Work with new business sales to onboard new clients * Established carrier/vendor relationships with appropriate contacts to assure smooth handling of all client administration (eligibility, claims, billing, plan administration, contracts, plans change, etc.) * Intake and track client and/or employee calls and emails with any issues using a client management system * Responsible for issue resolution for all client/employee questions/concerns.
Contacted carriers/vendors on behalf of clients/employees * Managed the Request for Proposal process including the compilation of market responses and worked closely with Account Executives to ensure deadlines are met * Worked closely with the Cross functional teams (Implementation Manager, Client Manager, Call Centre and Technical Staff to determine goals and strategy * Maintained all appropriate documentation for book of business * Reviewed SPD's and plan documents for compliance and compared them to benefits that were sold to the client.
Ensure all benefits are accurately represented and request any changes from carriers as deemed appropriate * Maintained internal client management system with all client information.

08/2011 to 06/2013

AssociateCigna Healthcare - Phoenix, AZ

Reviewed and analyzed implementation materials to created documents for new and existing business.
Reviewed and analyze plan documents/contract language for language, errors, omissions, and compliance.
Analyzed benefits to ensured they are in compliance with legislation, load benefit in the system.
Researched, coordinated information, and responded to questions from internal partners and/or external clients, first point of contact from customer to resolved issues.
Identified process improvements for own cases directing removal of non-complaint information.
Reviewed and analyzed plan documents/contract language, negotiate deliverables with internal partners.
Audited accounts to determine compliance with required state specific health mandated overages such as Autism coverage, well child coverage, postpartum care, and TMJ.
Handled multiple financing arrangements (Fully Funded, ASO, and Minimum Premium).
Developed calculations to ensure automated claim payment, interpret benefits to design plan specifications.
Load/enter calculations into the system.

12/2010 to 07/2011

Client Benefit AnalystCVS Caremark/Remx - Phoenix, AZ

Performed claim adjustments/reconciliations for Medicare Part D across processing platforms.
Researched and analyzed participant claims activity, plan design, and CMS guidance in determining accurate claim payments and accumulations.
Performed calculations or validation for claim payment/reconciliation determination for overpayments, underpayments.
Executed accumulation adjustment and/or participant reimbursement.

08/2010 to 10/2010

Benefit AnalystXenosoft Technologies - Phoenix, AZ

Participated in the system area configuration activities surrounding the defined, designed, build, unit-testing and configuration loaded phases under the direction of the Lead Configuration BA.
Analyzed client documentation pertaining to benefit plans including but not limited to Summary Plan Descriptions (SPD's) and Certificates of Coverages to identify the various service category offerings and variations across plans.
Identified the number and type of base benefit packages that will be built to support all of the sold benefit plans.
Used understanding of Specific State Mandates for various services such as Autism coverage, Home Health, and Healthcare Reform.
Created and executed unit test plans for review, corrected any errors and omissions prior to submitting to QA for quality review.
Built new base benefit packages by copying the main base benefit package and applying the appropriate changes.

03/2009 to 06/2010

Contract AnalystCymetrix - San Diego, CA

Loaded contract terms in managed care denial system; maintained and edited terms.
Ensured accurate pricing of claims in order to have the Account Management Staff collect underpayments timely from the insurance carriers affected.
Trained 10 operations personnel regarding the terms of the contracts governing accounts to be audited.
Reviewed clients' contracts in a timely fashion with managed care payers and entered contract terms in databases in such a manner as to price claims consistently with the terms of the corresponding contract and to maximize client revenue.

12/2007 to 07/2008

Claims AnalystShared Savings/United Health Networks - San Diego, CA

Fee negotiated out of network claims with our re pricing vendors such as First Health, Beech Street, Multiplan, and BCE Emerges.
With discounts provided between 15 to 25 percent savings from a traditional non network benefit.
Provided Non network providers with a competitive reimbursement, than traditional out of network benefits.
Reduced Member out of pocket liability, with the reprising costs maximizing reimbursement from the health insurer.

04/2004 to 12/2007

Claims AnalystSpecialized Care Services/Optum Health - San Diego, CA

Performed claim reviews audits, determined if payments and/or benefits were paid and processed correctly.
Managed high risk providers from filing additional Department of Insurance Claims, reducing claims error fall out and provided direct customer support to include reviewing, processing or adjusting, and/or auditing claims.
Documented findings on Excel and provide internal claims and customer support to Account Management, Network Management, CNS, Care Managers, members, as well as providers.
Researched benefit plans, provider setup, and fee schedule errors, routed requests via EPuf to correct errors and omissions; updated systems affected.
Prepared reports for Medicare and Medicaid claim adjustments for submission to Eau Claire for processing.
Reviewed Idrs (Integrated Data Retrieval System) to verify claim submission information.
Used understanding the various reimbursement methodologies and practices to determine what fee schedules, determine overpayments, underpayments, calculate interest and penalties Adjusted claims, initiated overpayment requests, and submit requests for stop payments.

Education and Training

Select One

2006

GraduatedAmerican InterContinental University - Schaumburg, IL

Organizational Psychology and Development

2007

Associate of Arts: Business Administration Healthcare AdministrationAmerican InterContinental /University - Schaumburg, ILBusiness Administration Healthcare Administration

Skills

Account Management, auditing, Autism, BA, benefits, billing, book, Call Center, CMS, competitive, client management, contracts, copying, Client, clients, customer support, databases, directing, direction, documentation, fashion, filing, financing, functional, Home Health, Human Resources, Insurance, market, materials, Excel, Works, Network Management, network, personnel, pricing, processes, Proposal, quality, QA, sales, strategy, troubleshoot, troubleshooting, type, validation

Affiliations

Resume Overview

Companies Worked For:

Care 1st Health Plan
Xerox, Total Benefits Outsourcing
Cigna Healthcare
CVS Caremark/Remx
Xenosoft Technologies
Cymetrix
Shared Savings/United Health Networks
Specialized Care Services/Optum Health

School Attended

American InterContinental University
American InterContinental /University

Job Titles Held:

Fee Schedule Analyst
Project Analyst
Associate
Client Benefit Analyst
Benefit Analyst
Contract Analyst
Claims Analyst

Degrees

Select One
Graduated
Associate of Arts : Business Administration Healthcare Administration

Fee Schedule Analyst Resume Example

Resume Score: 90%

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