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Manager Cost Containment Recoveries Resume Example

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Jessica Claire
  • Montgomery Street, San Francisco, CA 94105
  • H: (555) 432-1000
  • C:
  • resumesample@example.com
  • Date of Birth:
  • India:
  • :
  • single:
Professional Summary

High impact Business Analyst, Leader, and Manager adept at leading teams to realize business goals and objectives. Insightful Manager with experience directing and improving operations through effective employee motivational strategies and strong policy enforcement. Proficient in best practices, market trends and regulatory requirements of healthcare payment integrity operations. Talented leader with analytical approach to business planning and day-to-day problem-solving.

Skills
  • Databases: SQL Server and Microsoft Access
  • Programming Languages: SQL, Python, and Visual Basic for Applications.
  • Data Visualization: Tableau, SAS Enterprise Guide, and MS Excel
  • Process Mapping: Visio
  • Data Mining & Analytics
  • Staff Management
  • Strategic Planning
  • Business planning
  • Leadership Development
  • Consulting & Coaching
  • Statistics
  • Vendor Contracts
  • Customer Service
Work History
Manager, Cost Containment & Recoveries, 03/2019 to Current
Centene Corporation Russell, AR,
  • Key Accomplishment: Led in identification and recovery of $25 million dollars in overpayments through internal and vendor related efforts.
  • Responsible for leading high performing staff of 8 to manage multiple lines of business including Medicaid, Medicare-Medicaid, and all other lines of business as identified to mitigate fraud, waste, and abuse.
  • Ensure federal and state contractual expectations are maintained for each line of business as it relates to claim payment accuracy guidelines.
  • Responsible for auditing of claim payment system, identifying overpayments, managing overpayment recoveries, and identifying process improvement opportunities.
  • Research, identify, and recover overpayments related to fraud, waste, and abuse.
  • Establish acceptable claim auditing programs, processes and policies to ensure accurate payment of claims.
  • Develop in-depth understanding of all claim systems that impact payments.
  • Identify trends and processes for improvement and lead efforts to implement changes to improve overall quality.
  • Perform periodic contract audits to ensure billing and payments are in accordance with contract terms.
  • Perform periodic fee schedule audits to ensure fees are current and accurate.
  • Review and participate in implementation of new coding changes, example new CPT and ICD-10 changes.
  • Serve as Cost Containment lead for new system and process implementation projects.
  • Develop strategies for evaluating process efficiency and effectiveness.
  • Create and implement strategies for managing vendor effectiveness.
  • Develop strategies for make-buy decisions for auditing payment methodologies such as subrogation, NCCI, and various payment groupers such as APC, AP-DRG, MS-DRG, and GAPE.
  • Handle miscellaneous duties/activities as directed by senior management.
Business Analyst III, 03/2018 to 03/2019
Virginia Premier City, STATE,
  • Key Accomplishment: Identified and recovered over $1.5 million dollars in overpayments.
  • Lead Analyst in supporting the Cost Containment Unit in identifying, validating, reporting, and recovering health insurance claims overpayments resulting from inaccurate, fraudulent, wasteful, or abusive billing practices.
  • Led initiatives that supported efforts in recovery and cost avoidance.
  • Partnered with manager and other leadership to identify and develop overpayment recovery and cost avoidance opportunities, and refine and maintain after delivery.
  • Identified opportunities to reduce health insurance fraud, waste, and abuse across Medicare and Medicaid plans.
  • Performed contract reviews to ensure proper claims payment.
  • Collaborated with Systems Configuration teams to identify gaps in claims payment logic and benefits configuration.
  • Created dashboard reports of avoided and/or recovered claim payments.
  • Performed risk assessments associated with recovering overpayments.
  • Led and managed department projects and initiatives.
  • Gathered business requirements and develop solutions for new initiatives and upgrades to existing processes.
  • Developed and distribute reports related to Cost Containment initiatives.
  • Performed data analyses for projects, documented all project status updates including contact information, overview, barriers, next steps, and accomplishments and maintain oversight of project plans ensuring all updates are made in a timely fashion.
  • Documented and maintained all task schedules and related deliverables.
  • Performed root cause analyses and coordinate corrective actions through Director and responsible parties.
  • Mapped process activities to identify shortfalls and propose options to rectify operational inefficiencies.
Senior Client Data Steward/Business Analyst, 05/2017 to 03/2018
EAB|Royall & Company City, STATE,
  • Managed all aspects of data acquisition and delivery process for over 28 clients in the higher education space.
  • Partnered with clients to understand their business objectives, gather and interpret data/information requirements, and work with internal account teams and client data specialists to define standards and rules.
  • Documented all client file data specifications and assist to maintain information regarding client data schedules and systems.
  • Guided and set internal account team expectations regarding data needs and turn-around times.
  • Drove business efforts to develop practices and processes to collect, standardize, sustain and continuously improve quality of client data to support company and client programs and initiatives.
  • Executed required data tasks using SQL, JavaScript or MongoDB to support internal production processes, standardize client data and create client data files.
  • Ensured client data is accurately transformed and compliant with defined standards and rules.
  • Resolved data discrepancies; coordinate and communicate data issue resolution with clients and internal parties.
  • Facilitated client calls, in-person meetings, etc., to build effective relationships.
  • Mentored and support other client data stewards, resolve difficult client or complex situations for win- win results, trouble-shoot challenging client data tasks.
Education
Doctor of Strategic Leadership : Strategic Leadership & Coaching , Expected in 05/2014
to
Regent University School Of Business & Leadership - Virginia Beach, VA,
GPA:
Master of Divinity: Congregatonal Leadership, Expected in 05/2006
to
Anderson University - Anderson, IN
GPA:
Bachelor of Science: Computer Information Systems & Management, Expected in 01/2002
to
Lehman College Of The City University Of New York - The Bronx, NY,
GPA:
Additional Information

Awards: Faculty of the Quarter July 2014 Faculty of the Quarter Summer 2014, Strayer University (Chesapeake Campus) for outstanding student engagement. Harry L. and Henrietta Harp Memorial Award March 2006 Harry L. Henrietta Harp Memorial Award, Anderson University School of Theology for the most outstanding accomplishment in Congregational Ministries, Magna Cum Laude, Herbert H. Lehman College (City University of New York)

For a full work history, please visit my LinkedIn profile at https://www.linkedin.com/in/drnavonlindojr/

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Resume Overview

School Attended
  • Regent University School Of Business & Leadership
  • Anderson University
  • Lehman College Of The City University Of New York
Job Titles Held:
  • Manager, Cost Containment & Recoveries
  • Business Analyst III
  • Senior Client Data Steward/Business Analyst
Degrees
  • Doctor of Strategic Leadership
  • Master of Divinity
  • Bachelor of Science

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