Heather Virgulto

*** ******* *******, *******, **. 06460

Home: 203-***-****- acs26t@r.postjobfree.com

Professional Background

Dependable, hard working professional with excellent analytic skills, strong customer service skills, with specialties in Health Insurance including extracting and reporting on daily inventory and production, processing of claims, research and adjustments, provider demographic loading, third party insurance carriers, claims auditing and root cause analysis. Implement processes to improve overall efficiency in my work environment.

Skill Highlights

MS Excel, MS Word, and MS Power Point, MS Outlook and MS Access

Phycon, Epic and Eclipses Data Base

MC400 database, AS400, Lotus Notes database- Facets Database

Macess EXP, and SOX (Sarbanes Oxley) reporting

Xifin, Uniflow and Allscript, Medical Terminology, ICD-9 and coding

Professional Experience

Facets Provider Data Configuration Specialist

November 2014-July 2015

BroadPath-AZ

Review submitted claims for accurate information.

Research and verify a valid license, valid NPI, and valid information on groups and provider claims submission.

Review Facets database, researching for previous data entries for each group and provider.

Add payers’ information data to Facets ensuring correct fields are added per guidelines.

Work with Facility and all provider types.

Escalate any issues that may cause issues within database.

Appeal Specialist

May 2014-October 2014

Transgenomic Inc- New Haven, CT

Work in Xifin database to correct information from the HL7 data transfer from Uniflow.

Identify issues within Xifin and escalate to Director.

Monitor Unpricable and Error Processing errors and correct daily.

Validate information in Uniflow and Xifin database to insure accurate matching data

.Enter new Accessions into Xifin.

Responsible for entering new institutions into Xifin daily.

Worked on special projects from Director.

Print and send clinical documentations to insurance companies for review.Send appeal letters to insurance companies and follow up for payments.

Call insurance carriers to obtain authorization for services.

Make phone calls to insurance companies to follow up on unpaid claims.

Identify payment posting errors in Xifin.

Supervisor

November 2011-October 2013

United Healthcare- Trumbull, CT

In charge of extracting and formatting inventory and production reports daily and monthly from databases to obtain accurate data for associates who report to me.

Overseeing and managing two provider demographic loading teams.

River Valley Facets and HP Demo while working closely with offshore Managers and Supervisors to assist in overall production and inventory goals.

Assist my teams and business partners to increase work processes to meet company turnaround times set for crucial states.

Ensure new groups configuration is set up properly for payment.

Schedule and held meetings with my teams and Business Partners weekly to improve work processes.

Trained associates that were promoted to Senior Data Loading Analysts.

Ensure escalation emails and issues are handled in timely manner to meet turnaround times.

Work with Network Management to ensure smooth adjudication and accuracy of projects deadlines met and to find efficiency and process improvement's for project submissions.

In charge of writing Policy and Procedures for my teams work guidelines and working with training team to have implemented.

Work with new groups to configure how providers need to be set up for proper payment and how much the incoming work load would be.

Train new hires to ensure production is met by the end of ramp up time.

Ensure both teams remain above 95% of TAT for quality and 97 % for production monthly.

Work with Community and State Business Partners and key State Markets.

Business Analyst

January 2007- December 2010

Health Net

Responsible for running, reporting and validating all morning inventory reports for claims inventory for NY, NJ and CT and Arizona claims daily.

Responsible for running, reporting, and validating Sarbanes Oxley report for claims department daily.

Monitor inventory levels for an average daily volume of 80,000- 140,000 claims for HN plan, including Commercial, Medicare, Medicaid, ASO and HSA plans.

Created inventory comparison reports for project improvement initiatives that creates operational claims efficiency and reduces cost savings benefits.

Monitor production of all claims production associates in order to obtain inventory goals of 75,411 to 85,079 for Northeast and 37,354 to 44,757 for Arizona.

Created and monitored all internal service requests for off shore vendors, including new hires, terminations of associates and gaining them computer access.

Supports and manages all offshore vendors' pended claims and collaborates with appropriate department for resolution.

Operates in full compliance with all laws, regulations, and training requirements for HIPAA, Healthcare Fraud, compliance training and ergonomics.

Technical Coach

January 2005- January2007

Health Net-Shelton, CT

Research and Adjustment Specialist

January 2001-January 2005

Health Net–Shelton, CT

Claims Processor

January 1998- January 2001

Health Net-Shelton, CT

Store Manager

November 1988-Novemeber 1998

Lechters Housewares-Milford, CT

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