Business Analyst Csr

Objective:

I would like to obtain a more challenging positions which will continue to utilize my skills and enrich knowledge and understanding that I have gained throughout the last 21 years with Health Net, Inc.

Experience Work:

Health Net/Centene 2019 –current

Provided one-on-one coaching in areas where analysts needed to be educated, most often identified through an error received or from an escalation received. Supported the team by monitoring inventory daily, assigning cases regularly and as escalated due to age, resolving questions, submitting/returning/assigning Verisk cases, assigning CapDeducts, and sharing the workload of other leads in their absence. Available to analysts throughout my shift and takes the lead on multiple requests daily without hesitation.

Has also assisted with coverage of completing daily tasks for the team’s Business Analyst. Zoom Meetings, meeting with the PDR Team. Training new hires, helping with Interviews. Flexible with task when given. Team Player always willing to help.

The Lead is responsible to identify performance deficiencies or areas of opportunity for staff, and provides support through coaching, feedback, guidance, and tools for the analysts to be successful in their performance. The Lead is responsible to take two or more online training courses on Leadership, Team Building, Engagement, etc. throughout the year, and apply what they’ve learned through Lead-guided team huddles or small-group focused training sessions.

Outlook, Skype, Spreadsheets, Microsoft word, Excel, Macess,IBM, production sheets

Claim Lead Analyst

Health Net, Inc. 2014- Current

Claims Anaylst

Process 1500 (Professional) and UB04 (Facility) claims from beginning to end

Process claim for payment, adjustment or denial according to member’s benefit coverage.

Processor for ambulatory surgical coding, durable medical equipment, ambulance, Hemo/Chemo, and vision claims.

Document workflow and assign appropriate denial EOC code and letter

Analyze and research provider’s appeals submission if appropriate adjustment is necessary

Escalate age claims and billing issues to avoid penalty of interest, per provider’s contract or non-par provider

Match authorizations/ referral submission on claims, when specific service procedure require prior authorization (ICD-9, CPT, & HCPCS)

Price service procedure code using BURGESS, AWP application, and State Health website when applicable to claim

Work on special projects researching to resolve system error, edit, and request for reimbursement

Lines of business experienced: Commercial California HMO, PPO, POS, EPO, Medicare (CMS), & Medi-Cal

Handles incoming calls related to the processing of claims from providers and members

Affordable Health Care Specialist/ Escalations representative

Complacence with HIPPA

HealthNet 2007-2014

Foreign Claims/Performance

Process Arizona claims using MC400 and Macess. Claim development by contacting providers and members for unclean claims.

Process all types of products; IFP, PPO, HMO, FLEXNET, CSP and Foreign Claims (out of the United States medical services) using ABS System, Macess and Intranet. Claims received via electronic and physical copies through inter-office hard copies and by fax. Contact members and providers via telephone and emails for development of unclean Research claims and analyze contract provisions to determine eligibility to authorize benefit payments. Comply with state federal regulations and requirements as they apply to claims. To manage health care products. Adjust under and overpayment claims and contract issues to ensure compliance with departmental regulations.

Healthnet 2004-2007

Claims Cap Deduct

Research, Pay claims mulitple lines talking with PNA, sending emails, process claims for payment and recover the money either on a monlty, quarterly, or annual basis data base, Lotus notes, ABS, all lines of business.

Health Net 2001-2004

Provider Services Research Admin Assisant III

Over seeing incoming mail, Input in access, Email requester, Communicate

With requester on status, Distrubute to the right researcher, Maintain Cabinets

, Filing projects, winscan Triage out of boxes, Answer Multiple phone lines,Data entry,

Train other employees.

Health Net 1999-2001

Member Services Admin Assisant II

Maintaining prompt outgoing, misc documents from CSR out boxes

Faxing, Copying, Setting up desk for new employees, Create Eob, ID cards

In microsoft, Filing, coping, winscan,

High School

John F Kennedy Diploma

Hobbies

Softball, Gym, Family

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