Compliance Analyst

Kristi Lee- Compliance Analyst

832-***-**** **********@*******.***

Objective:

Career minded Healthcare professional with over 10 years of experience providing exceptional service and quality which

consists of defining, measuring, analyzing, and controlling departmental policies and processes. As a result of identifying

defects and potential issues early-on, I’ve been effective at streamlining processes and finding more cost effective

approaches to meet the organizational bottom-line and positively impacting Business Owners, Stakeholders, and Delegate

vendor’s processes. My goal is to acquire a position with a company seeking a dependable, experienced healthcare

professional who will be instrumental in meeting and exceeding the company’s overall objectives.

Qualifications:

Advanced knowledge of Medicare (CMS) Regulations and HIPPA guidelines

Familiar with IDX, FACETS, EZ-CAP, EPIC systems (Insurance Processing Systems)

Advanced benefits knowledge of working with employer groups, preferred provider organization (PPO), managed care

advantage (MA and MAPD), health maintenance organization (HMO), private-fee-for-service (PFFS)

Expert in Medicare Payment Methodologies (CPT, DRG, APC, PPC, ASC groupers, Fee schedule, etc.)

Advanced knowledge of coordination of benefits (COB) processes

Proficient in Microsoft Office (Excel, PowerPoint, Outlook, Word, etc.)

Working knowledge of basic Accounting principles for financial validation

Excellent leadership, communication, verbal and written, and interpersonal skills

Strong organizational and project management skills

Successfully able to work with all levels of management and discuss potential deficiencies in efforts to prevent CMS

sanctions and Corrective Action Plans (CAPS)

Professional Experience:

Kelsey-Seybold Clinic –Houston, TX

Facility Analyst, 12/2011- Present

Skilled in analyzing, researching, and processing facility and professional healthcare claims in accordance to internal policies,

CMS guidelines, and contractual obligations.

Responsibilities:

Advanced understanding of diagnosis related groups (DRG) pricing methods, outpatient prospective payment

(OPPS) system mechanics, outliers and case rate payment mechanics Thereby ensuring proper payment is applied

and reducing the risk of overpayments and provider appeals.

Demonstrate clear understanding of CMS regulations and guidelines, organizational determinations, coverage

determinations, and appeals and grievance processes

Demonstrate strong working knowledge of contract interpretation and utilization review procedures (specific to

authorizations)

Advanced understanding of contract interpretation, fee schedules and reimbursement methods

Demonstrate understanding of regulatory guidelines (i.e. CMS, HIPAA, etc.) which aids in detecting system

issues therefore reducing costs associated with inaccurate payments/processing

Strong knowledge of Claims Services and Claim Review Processes

Effectively works as part of a team to set goals, prioritize work and coordinate execution of the work

Effectively interpret dual coverage policies(is this analyze since you use coordination also?) and apply

coordination of benefits (COB) processes

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Kristi Lee- Compliance Analyst

832-***-**** **********@*******.***

Strong knowledge of Claims Services and Claim Review Processes

Self-directed and able to absorb new material quickly

Effectively works as part of a team to set goals, prioritize work and coordinate execution of the work

Effectively coordinate and process coordination of benefits (COB) Claims

Universal American Corp. – Houston, TX

Compliance Analyst, 9/2008- 12/2011

Performed independent auditing and monitoring of various internal departments to ensure compliance with all applicable laws,

CMS regulations and regulatory obligations which were based on a 95% accuracy rate per CMS. Independent auditing and

monitoring included analyzing results, recommending corrective actions, and composing reports for senior management review.

Identified key issues in delegation oversight operations, final claims determination, timely payment, and interest on clean claims

paid late. Early detection allowed for cost effective approaches to implementing procedural changes to remain in compliance

with applicable regulations.

Also identified as a leader by the Senior Vice President and was selected to participate in management training for Lean Six-

Sigma Green Belt certification.

Responsibilities:

• Evaluated the adequacy and effectiveness of internal controls over assigned audit activities, including follow-

up on prior audit issues.

• Developed written reports which support the audit activity, including the testing performed and the audit

conclusions

• Expert consultant to management to offer guidance to resolve audit issues.

• Participated in the planning, development, and management of audit programs

• Developed effective and efficient recommendations to resolve audit findings and improve the control

environment

• Participated in special senior management directed reviews as assigned

• Collaborated with management during the audit to communicate and resolve audit issues. Documented

unresolved issues and proposes effective/efficient recommendations; presented findings and recommendations to

responsible operating management.

• Performed follow-up reviews to determine if appropriate corrective action, as indicated by management in

response to audit recommendations, were implemented and functioning as intended.

• Developed my skill set by remaining informed of current industry trends to include auditing and regulatory

issues. (i.e. attend training, online resources, etc.)

Coventry Healthcare – Harrisburg, PA (transferred to Houston Location in 2006)

Senior Integrated Claims Representative, 10/2001 -9/2008

Supported claims adjusters in processing various Health insurance claims. Analyzed and determined completeness and validity of

financial payment accuracy and adherence to processes. Delegated projects and team assignments. Trained and coached staff in

order to develop knowledge and skills to adhere to CMS regulations and departmental guidelines. Worked via telecommute for 4

years as the “Subject Matter Expert” being a resource to management as well as team members.

Responsibilities:

• Provided expertise or general claims support by reviewing, researching, investigating, negotiating, processing

and adjusting claims

• Authorized appropriate payment or refer claims to investigators for further review

• Analyzed and identify trends and provided reports as necessary

• Consistently met established productivity, schedule adherence, and quality standards

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Kristi Lee- Compliance Analyst

832-***-**** **********@*******.***

Resolved escalated calls and provided team training on financial accuracy, procedures, and processing

guidelines

Facilitated weekly meetings with all senior claims staff to remain abreast of all changes

Formulated daily reports and assigned aged-work to claims staff.

Worked via telecommute 3-5 days per week as a team lead resolving team issues via email or phone

Member of the coordination of benefits team (COB)

Education:

Pursuing BA in Business at Capella University, Expected completion 2014

Green Belt - Lean Six Sigma Training, August 2011

Medicare Part C and Part D Data Validation Training Certificate, February 2011

High School Diploma, Central Dauphin East High, Harrisburg, PA 1999

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