Kerlyne Metayer Joachim

ad4rlk@r.postjobfree.com 954-***-****

PROFILE SUMMARY

Experienced healthcare professional with a strong background in Provider Contract Analysis and Business Analysis. Recognized for adept leadership and analytical skills, I bring a wealth of expertise in optimizing operational processes within the healthcare sector. Proficient in leveraging data analysis to drive strategic decision-making, I have a proven track record of enhancing efficiency and performance. My ability to configure business systems and adapt to evolving industry landscapes enables me to thrive in fast-paced environments. Whether collaborating with cross-functional teams or working independently, I am dedicated to delivering exceptional results. With a keen eye for detail and a commitment to excellence, I am motivated to take on managerial responsibilities and contribute to organizational success. Eager to apply my skills and experience to drive innovation and drive business growth in a dynamic setting.

CORE COMPETENCIES

Expertise in analyzing provider contracts to optimize agreements and ensure compliance.

Skilled in evaluating business processes to drive efficiency and improve organizational performance.

Demonstrated ability to lead teams towards common goals with inspiration and guidance.

Proficient in utilizing data-driven insights to make informed decisions and solve complex problems.

Adept at managing multiple tasks, projects, and priorities to meet deadlines effectively.

Proven capability to thrive in dynamic, demanding environments, adapting to change seamlessly.

Strong interpersonal skills, fostering productive relationships across diverse teams and stakeholders.

Committed to introducing creative solutions and driving continuous improvement within the organization.

PROFESSIONAL SKILLS

Provider Contract Analysis

Business Analysis

Data Analysis

Process Improvement

Strategic Planning

Financial Analysis

Healthcare Regulations

Project Management

Risk Assessment

Vendor Management

PROFESSIONAL WORK EXPERIENCE

Provider Configuration Analyst-QNXT 5.9

Gainwell Technologies

April 2023 - December 2023

Led the QNXT Configuration team for system integration testing, ensuring seamless integration of QNXT with legacy extensions.

Utilized SQL queries for efficient uploads to QNXT and acted as Administrator for system management.

Educated providers and staff on Division of Financial Responsibility (DOFR) queries and interpretations.

Analyzed data from payers such as AETNA/AVMED, producing insightful reports on expenditure trends and utilization opportunities.

Established design for contracts and benefits based on thorough reviews of state policies and current business rules.

Ensured comprehensive provider specialty/Nurse Facility (LTC) contracts configurations were completed.

Updated benefit configurations for Medicaid and Medicare members during the QNXT/administrator migration.

Validated deductible and out-of-pocket maximums for accuracy.

Conducted thorough analyses for capitation contracts, determining configurations based on per-provider services.

Played a key role in end-user benefit/contract configuration using AAA-Analysis methodology.

Addressed client tickets and inquiries in ALM, ensuring prompt resolution and client satisfaction.

Quality Auditor-QNXT

NLS/EMIDS (Contract)-Texas Children

March 2022 - April 2023

Managed provider contract inventory for new client implementations, ensuring adherence to guidelines.

Reviewed and resolved claims issues through editing reports, providing adjudication support.

Verified appropriate guideline implementation in provider module setups.

Conducted database management and maintenance, ensuring data integrity in MPF files.

Configured QNXT Provider and Pricing files to maintain accuracy in payment systems.

Expertise in Division of Financial Responsibility (DOFR) and coordination of benefits (COB) interpretations.

Hands-on experience in claims processing, pend and send processing, and utilization management.

Developed and executed manual test cases from various requirement documents.

Conducted data validation and audit of existing plans and contracts in client databases.

Evaluated configuration requirements and formulated approaches based on best practices.

Collaborated with claims departments and credentialing teams to fulfill ticket requests and conduct fee schedule testing.

QNXT Provider Contract Configuration

Catalyst Solutions-Contract- AETNA

August 2021 - February 2022

Oversaw the loading of provider configuration requirements to ensure accurate claims processing.

Supported monthly capitation payments and reconciliations.

Conducted thorough reviews of Pend (A.I) reports for provider updates and corrections.

Researched and validated specialty groups and taxonomy codes for accuracy.

Functioned as Subject Matter Expert (SME) for testing systems after updates to ensure seamless contract uploads.

Processed PCR tickets requested by Claims team and Data entry team.

Provided strategic feedback to management based on A.I report findings to prevent errors.

Validated provider data via NPPES and generated reports for upper management.

Assisted claims teams with Benefit issues and developed organizational best practices.

Provider Contract Analyst-QNXT

Integrated Home Care Services, Inc

October 2019 - June 2021

Analyzed expenditure trends and utilization opportunities from payers like AETNA/AVMED.

Reviewed and credentialed providers with commercial and government payers.

Established and maintained strong relationships with payers to ensure contract success.

Addressed contract and benefit inquiries, providing timely responses to maintain production standards.

Collaborated with IT and audit teams to resolve provider contract issues and uphold quality standards.

Linked appropriate benefit profiles to patient accounts for accurate payments.

Updated IHCS contract system with benefits/contracts within established thresholds.

Managed recoupment requests for provider overpayments-accumulator update

Ensured compliance with Line of Business (LOB) standards per state guidelines.

Developed and tested prototypes for front-end Capitation system.

Handled payment disputes from providers, conducting thorough contract reviews.

Audited claims in the QNXT system for accuracy of coding rules and payments.

Configured Provider Contracts, Benefits, and Pricing in QNXT 5.6 and 5.8.

Created and executed test claims for User Acceptance Testing (UAT) to validate configurations.

Client Support/Special Projects

Advanced Recovery Systems

September 2018 - October 2019

Conducted audits to identify errors and reported findings to designated departments.

Identified denial trends and recommended process improvements for revenue cycle operations.

Participated in special projects as assigned, focusing on substance use disorder (SUD) claims.

Researched over-payment requests from payers and provided resolutions.

Validated payments based on contractual agreements with in-network payers.

Worked closely with AR Auditor and appeal specialists on clinical documentation for proper reviews.

Responded promptly to insurance requests for additional information.

Assisted with collections, running SQL queries for configuration accuracy.

Provided feedback to senior management on solutions for improved patient/vendor services.

Assistant Account Manager

Medrol Billing

April 2017 - September 2018

Spearheaded client retention initiatives, improving retention ratios.

Managed financial decisions to protect and collect revenues, adjusting Accounts Receivable (A/R) accounts.

Ensured accurate phone coverage, monitored call priorities, and shifts for effective operations.

Communicated staffing issues to senior management for timely resolutions.

Conducted monthly meetings with clients to review End-of-Month (EOM) reports.

Approved Payment-to-Patient (P2P) arrangements for private insurance and sub claims.

Configured QNXT Provider and Pricing files, ensuring accuracy in system operations.

Led a team of 7-10 collectors, managing their activities and ensuring goal achievement.

Analyzed A/R to review codes and denials, initiating projects to address non-payable items.

Collaborated with the VP of accounts receivable to meet weekly and monthly goals.

RCM Trainer/QA Team Lead-QNXT

Care Cloud Inc

September 2015 - February 2017

Directed day-to-day operations of client retention, contract enforcement, and account receivable management.

Played a pivotal role in meeting and exceeding customer expectations by maintaining high standards of collections.

Conducted audits on claims processed by Analysts, ensuring accuracy and compliance.

Oversaw an offshore team of 15 collectors and team leads, managing work schedules to meet client needs.

Developed and implemented retention programs and training initiatives for employees.

Generated invoices and EOM reports for customers/clients, responsible for claims follow-ups.

Collaborated with QA Team to identify and resolve highly defective accounts.

Resolved client concerns and complaints, improving client retention ratios.

Coached collection representatives on meeting customer expectations and ensuring timely resolutions.

Senior Collection Specialist

Care Cloud Inc

September 2015 - November 2015

Conducted account reviews and resolved denials for a client-based account (MCH).

Contacted insurance companies for clarification on denials and updated configurations as needed.

Generated and analyzed trends.

Claims Examiner - Medicaid (Physician) - QNXT

Simply Healthcare Plans,

July 2014 - August 2015

Generated detailed reports based on Medicaid products such as Simply, Better Health, and Clear Health ABA claims.

Handled incoming calls from both members and healthcare providers, ensuring prompt and effective communication.

Implemented efficient processing techniques to enhance productivity within the team.

Completed the configuration of QNXT 5.9 for Drugs & Injectables, Radiology, and Surgery benefits.

Identified emerging trends and corrected edits to prevent claims from being inaccurately processed.

Reported system-related edits to the Configuration department for further analysis and resolution.

Processed an average of 150 claims, maintaining a procedural and financial accuracy rate of 97% based on fee schedules.

Conducted thorough reviews of patients' benefits in accordance with the types of claims submitted.

Analyzed insurance contracts to align with member benefits, ensuring precise and timely payments.

Stayed updated with the latest ICD-9/CPT and Medicaid guidelines to ensure compliance and accuracy.

Responded to inquiries from member/provider services in a timely and professional manner.

Conducted system testing to ensure functionality and accuracy.

Utilized EDI-denial processes for electronic claims submissions and resolutions.

Collaborated with providers to address common registration errors and streamline processes.

Account Coordinator - Temporary Role

Carvel - Aerotech, June 2014 - July 2014

Extracted and reviewed weekly reports from vendor software to validate payments and ensure accuracy.

Conducted thorough reviews of workers' compensation claims for potential billing errors and denials.

Corrected identified issues in claims and rescanned them through the billing system for resubmission.

Identified and reported trends to management for proactive decision-making.

Communicated with site managers via email to inquire about outstanding payment statuses and resolve any issues.

Collection Analyst II (Lead) - Medicare

Health Financial Systems, Hollywood FL, November 2013 - May 2014

Successfully resolved denial trends by analyzing root causes and implementing effective solutions.

Developed directives and best practices for handling insurance denials, ensuring compliance and efficiency.

Verified and maintained providers' credentialing status for Medicare/Medicaid guidelines adherence.

Assisted and trained team members on Medicare/Medicaid guidelines, ensuring a knowledgeable and skilled workforce.

Resolved high-dollar accounts and followed up on high-alert invoices from upper management.

Maintained status levels of multi-specialty accounts, ensuring timely and accurate resolution of issues.

Conducted audits and reviewed employees' accounts, providing constructive feedback and guidance.

Identified trends to prevent mass denials and improve overall claim processing efficiency.

Managed quality assurance processes for invoices, providing feedback and training to enhance performance.

Reviewed daily reports to identify valid workable invoices and expedite resolution.

Interacted with clients daily to address issues affecting cash flow and maintain positive relationships.

Reviewed contractual agreements with insurance providers to ensure accurate and timely payment processing.

Completed posting errors and managed EDI 837P-COB processes for efficient claims handling.

Established and met goals with clients to ensure successful recovery of claims and continued partnership.

Reimbursement Specialist

Sheridan Health, Sunrise FL, August 2012 - November 2013

Completed individual projects based on specific insurance carriers, ensuring accurate and timely reimbursement.

Analyzed and identified common denial patterns, implementing strategies to prevent future occurrences.

Followed up on denied claims, contacting insurance companies for reconsideration and resolution.

Processed adjustments according to explanation of benefits (EOB), ensuring accurate billing.

Reviewed contracts with insurance carriers to ensure proper reimbursement and compliance.

Conducted payment posting and managed accounts receivable special projects, resolving issues and discrepancies.

Identified errors affecting claim processing and implemented solutions to streamline processes.

Reviewed contractual agreements between health insurance and hospital for accurate payment processing.

Recovered short-paid balances through recalculations of contractual agreements.

Conducted system checks and reported errors to the development team for resolution.

Ensured smooth operations by following up on system errors and resolving issues promptly.

Appeal Representative - Medicare

Revenue Cycle Management System, Fort Lauderdale, FL, April 2012 - July 2012

Reviewed claims for submission to secondary insurance, ensuring maximum reimbursement.

Followed up with healthcare insurance companies to secure proper payment in line with contractual agreements.

Conducted thorough reviews of medical records to proceed with first and second-level appeals.

Analyzed explanation of benefits (EOB) to determine patient responsibility and billing accuracy.

Verified insurance information for proper claim submission and addressed any discrepancies.

Corrected claims by requesting revenue code reviews through hospitals for resubmission.

Applied directives on how to tackle Medicare appeals within defined timeframes.

Reviewed reports to identify potential non-workable claims and take appropriate actions.

Completed write-off requests and adjustments, ensuring accuracy and compliance.

Provided weekly reports to clients on potential issues affecting reimbursement and claim processing.

Medicare/Medicaid Denial Recovery Specialist

HBS/Health Business Solutions, Griffin Rd, FL, May 2011 - March 2012

Reviewed and corrected rejected claims through Devonian and Invasion systems.

Submitted first-level appeals to Medicare Part A for maximum reimbursement.

Analyzed and corrected adjustment measures for Medicaid claims, ensuring accurate billing.

Maintained quota policy for efficient claim processing and resolution.

Utilized the common working file through DDE to determine patients' coordination of benefits.

Conducted training sessions for new hires on claims processing and denial recovery.

Medicare Liaison/Analyst Pal II

Holy Cross Hospital, Fort Lauderdale, FL, April 2008 - May 2011

Maintained and managed claims for HBP and HCH databases, ensuring accurate billing and timely resolution.

Followed up on overdue billings and resolved outstanding invoices with prompt and effective communication.

Corresponded with doctors' offices regarding denied and rejected claims, resolving issues efficiently.

Assisted office managers in identifying and implementing strategies for denial prevention.

Corrected and reposted claims with appropriate modifiers or procedure codes, ensuring accurate billing.

Reviewed patients’ account information verified insurance details, and reviewed claims prior to submission.

Submitted first, second, and third-level appeals to Medicare with accurate medical record data.

Reviewed and analyzed coordination of benefits and insurance payments for accurate billing.

Maintained quality and productivity standards according to hospital policies and procedures.

Responded to patients' payment concerns and resolved issues promptly.

Medical Collector/Self-pay

Complete Collection Services, Fort Lauderdale, FL, November 2006 - January 2008

Managed collections for hospitals and healthcare providers, overseeing accounts ranging from $3,000 to $100,000.

Verified insurance claims across a spectrum of carriers, including Medicaid, Medicare, Medicare Supplements, Workers Compensation, and Auto Insurance.

Managed write-off requests and placed accounts on hold for thorough review and resolution.

Addressed patients' inquiries regarding their account status with clarity and professionalism.

Established tailored payment arrangements with patients based on their income levels, ensuring fair and feasible plans.

Reviewed and promptly responded to patient correspondences, maintaining a high level of customer service.

Developed and implemented a comprehensive training manual for Iowa University Hospital, ensuring standardized processes and practices.

Provided thorough training to new hires, equipping them with the knowledge and skills necessary for effective call handling and account management.

Responded to inquiries from colleagues, offering guidance and support in navigating complex collection procedures.

EDUCATION

Master of Health Administration,

University of Phoenix

Bachelor of Science in Health Service Administration,

Florida International University

Associate of Arts in Health Service Administration,

Broward Community College, Davie, FL

Quality Assurance

Business Process Modeling

Report Generation

Stakeholder Engagement

Cross-Functional Collaboration

Problem-Solving

Software Proficiency

Contract Negotiation

Performance Metrics Tracking

Training and Development

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