provider cost of care senior analyst resume example with 8+ years of experience
JessicaClaire
, , 609 Johnson Ave., 49204, Tulsa, OK100 Montgomery St. 10th Floor
Home: (555) 432-1000
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Summary
Data Quality Assurance Management/ Analyst Professional with 14yrs experience with risk adjustment Medicaid, Medicare, and Commercial insurance. Experienced professional utilizing various data analytics, coding software and EMR systems. Performing healthcare/retail data analytics, risk adjustment medical coding, and healthcare data mining.
Skills
Knowledge of Analytics Programs
Financial and Economic Data
SWOT Analysis
Data Mining
BI Tool and System Design
Business Intelligence Systems
Business Analysis
Microsoft Office
Data Management
Quality Analysis
Data Analytics
SQL
Experience
Provider Cost of Care Senior Analyst, 09/2019 to Current Cano Health – Tampa, FL,
Utilize SQL to build, test and manage reports for hospitals and ambulatory surgical centers in the entire state of GA.
Developed moderately complex ROI models and performs healthcare cost analysis to identify strategies to control costs; projecting cost increases in medical services by using analytic techniques for PMPM trending via multiple variable analysis.
Preparing pre-negotiation analyses to support development of defensible pricing strategies; performing modeling to compare various contract scenarios based on member utilization patterns and 'what if' logic; measuring and evaluating the cost impact of various negotiation proposals.
Research financial profitability/stability and competitive environment of providers to determine impact of proposed rates; and projecting different cost of savings targets based upon various analytics.
Translate database reporting needs into SQL queries that extract data and create relevant reports.
Utilize SQL to build, test and manage reports.
Risk Adjustment Coder, 09/2017 to 12/2022 Realtor.Com – Los Angeles, CA,
Experience working in and with Risk Adjustment model software (HCC, RxHCC, ESRD)
Responsible for review of Medicaid, Medicare and Commercial outpatient and inpatient complete medical records validating accurate assignment of all documented Risk Adjustment HCC ICD9/10 diagnosis and procedure codes.
Responsible for consistently coding at 95% accuracy quality while maintaining client specific production standards of 100 chart completion per week.
Responsible for adhering to Center of Medicare and Medicaid Services (CMS) for the Risk Adjustment Payment Systems (RAPS) are appropriate, accurate and support clinical documentation in accordance with State and Federal regulations and internal policies and procedures.
Abstract pertinent information from assigned medical records using ICD-9-CM, CPT and/or HCPCS codes
Senior Data Analyst, 02/2018 to 09/2019 Sedgwick Claims Management Services Inc. – City, STATE,
Performed accurate and thorough analysis of data, presenting all results using SQL, MS Access, Excel
Assists in efficient and effective program management; identifies poor work quality and cost effectiveness trends; and works with appropriate staff in analyzing and compiling data from technical reviews, as applicable.
Analyze data for cause-and-effect ratios, return-to-work and accommodations trending, disability durations, injury by job type analysis, disability diagnosis trending, etc.
Solved challenging data integration problems, utilizing optimal extraction transformation load patterns to reach resolutions.
Used business objects and intelligence to extract data from software-based solutions and information warehouses.
Data Quality Assurance Manager , 11/2016 to 06/2017 Marsh & McLennan – City, STATE,
Executed and implemented healthcare 837 and 835 file EDI data validation, data integrity, data profiling, data auditing and data gap analysis for 200+ clients.
Developed healthcare eligibility, pmpm, HCPCS and diagnosis code metric dashboards that track 200+ clients overall employee healthcare population.
Responsible for educating and communicating appropriate data quality measures awareness with Internal and external stakeholders.
Corrected and cleaned historical medical data that had not been corrected upstream via EDI. Ultimately, assisting with development of efficiency within carrier healthcare informatics teams to ensure medical claims files were provided with necessary file elements going forward. This resulted in ensuring all 200+ that utilized this carrier file feeds were provided with correct elements.
Conducted root cause analysis for 200+ clients monthly that contained a healthcare data variance over 8%, greater than 30 days. Created a Planning Analytics for Total Health Stoplight report that provided daily updates on all EDI system resolutions for the entire market.
Responsible for EDI data governance activities and monitor healthcare data quality metrics pertaining to the accuracy and completeness of health care data information for 200+ clients.
·Responsible for working directly with Carriers healthcare informatics team, Pharmacy Benefit Manager (PBM), Data Repository Vendor, analyst, and support staff for resolutions of EDI issues.
Responsible for providing guidance to less experienced colleagues as needed.
Conducted analysis on quality of data based on medical (inpatient, outpatient, ancillary), pharmacy and eligibility claim file feeds based monthly thus reducing reporting error rate to 20%.
Utilize coding knowledge of ICD9 and ICD 10 to ensure medical claims, pharmacy claims contain appropriate codes within healthcare claims transmission to Data Warehouse Repository vendor.
Utilize the DMAIC system to identify and reduce future data integrity issues.
Responsible for educating carriers IT/Informatics team based on performance scorecards to help reduce bad data transmission.
Maintained policy, procedures, work instructions and projects for quality and continuous improvement agendas.
Identified quality trends to investigate system flaws, process inefficiencies and training needs.
Worked with Agile and Scrum methodologies to accomplish project milestones and meet demanding timelines.
Senior Data Analyst Team Lead, 05/2014 to 05/2016 Marsh & McLennan – City, STATE,
Responsible for development of SQL data queries that serviced the national platform.
Analyzed statistical Commercial healthcare data, performed data queries, working with brokers/account managers/consultants to educate on the impact of healthcare utilization patterns.
Evaluated performance benchmarks and established review metrics for future tracking.
Continually refined data input / output to optimize department production and efficiency. This resulted in website development of key reporting metrics for al clients utilizing the Planning Analytics for Total Health department P.A.T.H
Cultivated and managed relationships with providers of source data (carriers, pharmacy benefit, managers, etc.) to ensure optimal production within department. .
Education and Training
Master of Science: Healthcare Informatics, Expected in 05/2011 to University of Central Florida - Orlando, FL GPA:
Bachelor of Science: Supervision Management , Expected in 05/2009 to Daytona State College - Daytona Beach, FL GPA:
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