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Jessica Claire
Montgomery Street, San Francisco, CA 94105
Home: (555) 432-1000 - Cell: - resumesample@example.com - -
Professional Summary

Expert Analyst with proven history of enhancing healthcare operations. Proficient in best practices, leadership strategies and employee motivation to boost productivity and job performance. Well-coordinated in addressing problems, investigating root causes and implementing successful resolutions.

Skills
  • Contract auditing
  • Motivational leadership style
  • Excellent communication skills
  • Policy and procedure adherence
  • Troubleshooting
  • Excellent problem-solving abilities
  • Configuration management
  • Cross-platform testing
  • Microsoft SQL Server
Work History
04/2016 to 01/2020
LEAD CONTRACT IMPLEMENTATION ANALYST Centene Corporation Barnhart, MO,
  • Deemed provider contracts, letter of agreements, amendments and supporting documentations as configurable by ensuring that the contractual obligations of the contracts are met with accordance of CMS guidelines for the Medicaid and Medicare product lines
  • Assessed and reviewed MS Division of Medicaid websites for reimbursement rate and benefit updates and submits changes for the system to be updated accordingly and timely
  • Ran reports using Golden and/or Teradata Databases consisting of claims data, fee schedules and cpt codes using MS SQL queries
  • Performed root cause and analysis for pended claims and submitted updates to Amisys, claims payment system, reducing the pend volume by 90% which prevented the claims from drawing interest
  • Trained and supervised new and existing employees ensuring that systems accesses are in place and policies and procedures are followed accordingly and provides ongoing support daily to the staff
  • Ensured accurate system configuration by submitting Change Requests through ServiceNow and following through to post-production on audits of claims payments that were related to CPT codes, ICD-10 diagnoses codes, APR-DRG inpatient hospital pricing and provider setups by performing User Acceptance Testings (UAT) on various scenarios
  • Developed and incorporated organizational best practices into business applications by formulating and updating departmental policies and procedures
  • Coordinated problem solving efforts between various business units to ensure that the best business practices are in place for the members as wells as the providers
  • Ensured health plan's network adequacies are met for specific provider specialties that impacts the entire State of MS and the neighboring states by running GEO Access reports using the Quest Analytics software
01/2012 to 04/2016
Senior Contract Implementation Analyst Corvel Yonkers, NY,
  • Performed audits of provider setup within the provider information system to ensure accurate contract implementation and subsequent claims processing.
  • Reviewed and manually priced claims that were pended in order for payments to providers to be released with payment accuracy.
  • Ensured accurate system configuration by submitting Change Requests through ServiceNow and following through to post-production on audits of claims payments and provider setups by performing User Acceptance Testings (UAT) on various scenarios.
  • Troubleshooted and problem solved contract implementation issues related to basic system configuration.
  • Reviewed contracts and assigned pay classes and applicable provider information based on contract language and established state guidelines.
  • Trained and supervised new and existing employees ensuring that deadlines and proper procedures were met accurately and timely.
  • Ensured health plan's network adequacies were met for specific provider specialties that impacted the entire State of MS by running GEO Access reports, Performed audits of provider setup within the provider information system to ensure accurate contract implementation and subsequent claims processing.
  • Reviewed and priced contract related pends to ensure claims payment accuracy.
  • Ensured accurate contract implementation and subsequent claims processing through provider setup which involved, Scopes, and User Acceptance Testing (UAT) on Change Requests (CRs).
  • Troubleshooted and problem solved contract implementation issues related to basic system configuration.
  • Reviewed contracts and assigned pay classes and applicable provider information based on contract language and established state guidelines.
  • Trained and supervised new and existing employees ensuring that deadlines and proper procedures were met accurately and timely.
06/2010 to 01/2012
PROVIDER RELATIONS SPECIALIST I CENTENE CORPORATION City, STATE,
  • Served as primary contact for providers as a liaison between the providers and the health plan, educating providers on the health plan's innovative contracting strategies
  • Conducted monthly face to face meetings with the providers documenting discussions, issues, attendees, and action items
  • Investigated, resolved and communicated provider claim issues and changes
  • Educated providers regarding policies and procedures related to referrals and claims submission, web site education, EDI solicitation and problem solving
  • Performed provider orientations, and ongoing provider education, including writing and updating orientation materials
  • Initiated data entry of provider-related database information and oversee testing and completion of change request for the network
Education
Expected in 12/2021
Bachelor of Science: Business Administration And Management Information
Southern New Hampshire University - Hooksett, NH
GPA:
Expected in
: Business Administration Information Technology
Columbia Southern University - Orange Beach, AL
GPA:
Expected in 05/1985
Associate of Applied Science: Data Processing
Copiah-Lincoln Community College - Wesson, MS
GPA:

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Resume Overview

School Attended

  • Southern New Hampshire University
  • Columbia Southern University
  • Copiah-Lincoln Community College

Job Titles Held:

  • LEAD CONTRACT IMPLEMENTATION ANALYST
  • Senior Contract Implementation Analyst
  • PROVIDER RELATIONS SPECIALIST I

Degrees

  • Bachelor of Science
  • Some College (No Degree)
  • Associate of Applied Science

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