Customer Service Insurance

DAWN WATSON

Objective: To Secure a position that will afford me an opportunity to use

and develop my skills knowledge and abilities.

EDUCATION: 01/1999 to 12/1999 FDCPA Training Course, East

Rutherford, NJ

Course of study: Federal

Collection Guidelines

09/1990 to 05/1992 American

Banking Institute, Livingston, NJ

Course of study:

Credit/Collections and Mortgage Serving

07/1987 to 05/1990 Kean

University, Union, NJ Course of study: Computer SC/ Music

EXPERIENCE:

07/2016-Present Metroplus Health Plan a subdivision of New

York City Health + Hospitals

Training and Audit Specialist

for Medicare, Medicaid and Manage care products

. Open Enrollment Verification (OEV) telephonic

validation.

. Open Enrollment Verification (OEV) Audit

. Medicaid and Manage Care Audit projects

. Demographic Updates

. Training Test Call for Customer Service

. Any all duties related to training and auditing of

Medicare, Medicaid and Manage care products

03/2016-0/2017 Benefits Coordination Recovery Center

(BCRC), contractor for Medicare Secondary payer (MSP)

for NON-GHP, a division of GHI-EMBLEM HEALTH.

. Become proficient in the operations of the Medicare

Secondary payer (MSP) for NON-GHP contract according to

CMS guidelines.

. Conduct audits and assessments of all aspects of the MSP

operations to support and facilitate quality, effective,

and efficient operations.

. Assist in meeting overall quality objectives identified

by the CMS and GHI/EMBLEM HEALTH.

. Understanding and assisting departments and

subcontractors in maintaining proper and necessary

controls for work processes and requirements compliance.

. Identify and promote process improvement to enhance

the effectiveness and the customer's satisfaction

. Analyze audit areas processes, controls, risks, and

benefits in accordance with the audit methodology.

. Strong oral and written communication skills.

. Articulating and documenting audit findings and

resolutions clearly, concisely, paying attention to key

details in a timely fashion.

. Apply GAAP, COSO, ISO 9000, and CMMI auditing standards

to all audits and reviews.

. Assess performance of the quality system. These reviews

will include system and data processing, call center

performance, mail scanning and sorting, electronic data

exchange, and financial analysis.

. Plan and conduct operational and financial audits.

Performing walkthroughs of operations and interviews

with area management to determine workflows and

associated business risks and controls. Develop planning

documents (planning memo and audit program) to support

audit objectives, scope, testing strategy, evidence

gathering and audit schedule.

. Identify issues and exceptions during testing; cause,

impact, and potential recommendations for submission to

area management and inclusion into the audit report.

. Track implementation of corrective actions resulting

from audits and other quality assurance reviews as

required by management.

. Utilize statistical/random methodologies to select

appropriate samples of transactions for testing in

accordance with the defined testing strategy.

. Prepare work papers to document evidence and testing.

Work papers must be clearly indexed and cross-

referenced.

. Assist the Quality Assurance Team in facilitating

quality operations, cost efficiencies, and process

improvements to enhance the quality management system.

6/2015 to 12/2015 Horizon Blue Cross Blue

Shield of NJ

Contract Configuration

Analyst for midsize to large business groups.

. Data mapping and pushing account to customization

. Assigning accounts to an analyst

. Customizing individual contracts and benefit handbooks

. Review benefits in CPL and BIF applications

. Distribution of hard and soft copies of the contracts

and handbooks to clients.

. Detailed reporting of any errors in the customization

formula in the Thunderhead application

06/2014 to 05/2015 Value Options@ Horizon BCBS of NJ

Quality Analyst for

Denials, Appeals and Grievances

. Coordinate appeals process as assigned, attends to risk

management issues associated with case management and

processes appeal requests. Review all written

correspondence and phone call to maintain regulatory

standards.

. Maintains a caseload and monitors day to day compliance

of appeal decision time frames.

. Reviews inpatient and outpatient medical records for

completeness and determines administrative or clinical

appeal; assigns clinical appeals to Physician Advisors

for medical necessity reviews.

. Enters all data related to appeals and case reviews into

a database.

. Prepares and presents information on appeals to panel's

second-level multi-disciplinary committee.

. Participates in data gathering and analysis of reports

regarding appeal activity as well as preparing for

appeals audits, provides new employee training, monitors

QI activities of appeals department, and assists in the

development of depart flows and implementations.

. Coordinates and distributes first, second and third level

appeal request assignments.

. Consults with Managers on problem cases and interfaces

with case managers, clinical supervisors, account

managers and other MBC personnel in resolving denial and

appeal questions.

. Responds to member, provider, and client telephone

inquiries regarding status, process and outcome of

appeals

. Organizes volume of work and work-flow so that

performance standards and proper procedures for appeals

resolution according to client requirements and state and

federal regulations are addressed.

11/2013 to Present US-REPORTS Hillside NJ

Independent

Premium Auditor

. As an Independent Premium auditor, I work for myself,

auditing business owner's commercial Insurance policies

for workers compensation or general liability renewals or

enrollments.

. Reviews the records of a business where an insurance

company has written a policy, either for workers

compensation or general liability coverage.

. The records to be reviewed generally include payroll, tax

reports and sales records, depending on the coverage and

type of audit we are doing.

. This information is recorded by the auditor and put in to

our software program.

. From this information, the insurance carrier can adjust

the premium to be paid by the insured (the business).

. All work is received and submitted online via a secure

website. All work is considered "paperless".

04/2013 to 07/2013 Express Scripts INC. Montvale NJ

Business/Data Analyst

. Responsible for reconciling Employer Group Medicare

Account and justifying the payables verses receivable:

. Analyze and solve problems in order to recognize trends

or anomalies

. Reconciliation: Researching across multiple systems to

indentify root cause of error and submit corrections to

third party vendor. Analyze data and provide reporting to

supervisor in excel spreadsheet or access database.

Tracking outstanding payments and supporting documents.

Follow up in a timely manner until resolution is met.

Manage daily system access request from 3rd party

vendors. Reconcile Express Scripts billing invoices

against Client's remittance. Provide the finance

department tangible proof for refunds, credit balances,

and adjustments. Creating weekly, monthly, and yearly

reports for 6 large accounts and 10 small accounts.

. Healthcare Patient Financial service for prescription

coverage.

02/2013 to 04/2013 EMBLEM HEALTHCARE INC New York NY

UAT Tester for Hospitals ICD 10 Conversion

. Responsible for test execution activities for assigned

projects within the ICD 10 conversion process, involving

support for assigned applications and frameworks

including:

. User Acceptance Testing: Creating and executing the UAT

test plan and cases including regression testing by the

UAT team. Conducting UAT testing, regression testing in

UAT, and ensuring all test results are properly

documented with screen shots, etc, as appropriate.

Validating defects and assignment for correction

. Testing the content and accuracy of reports based on user

requirements. Developing and documenting test processes.

Develop queries, analyses, or reports from applications

for operations or management staff of assigned business

unit. Working knowledge or experience with databases and

query techniques. Data mapping and validation experience

from source system to target system. Create/compile

specific test data, as needed

. Analyze and solve problems in order to recognize trends

or anomalies

. Responsible for execution of test cases (both manual and

automated), reporting defects, and development of test

cases/test data to certify defect fixes.

. ICD 10 Conversion process: In addition to standard

testing for compliance with format and content.

. Ensuring a seamless transaction for the ICD-10 migration,

I preformed end to end testing. This included validation

of format and content. Visibility into and accountability

for transaction flow through multiple process steps

including transformation and cross walking. Most

importantly, I provided analysis for management of

revenue cycle and risk models used by providers and

payer business outcome.

10/2011 to 01/2013 HORIZION BLUE CROSS BLUE SHEILD OF NJ

Newark, NJ

Business & Premium Reconciliation Analyst for Medicare

Products

. Duties included all phases of business and premium

reconciliation for Medicare products in accordance CMS

guidance. With use of multiple system Nasco, Ika

Medicare, QBlue, NMS.

. Business Process Analysis: Analyzed business needs to

determine optimal means of meeting those needs. Ensuring

business needs directly comply with CMS guidance and

timeliness.

. Determined specific business application software

requirements to address specific business needs.

. Marry the business processes to the systems capability.

Participated in developing and/or modifying requirements,

business design specifications, user training and

documentation. Researched and documents business issues.

Translated business requirements to technical staff to

ensure that requirements are incorporated into system

design and testing. Tested and documented solutions.

Served as liaison between the Medicare Service staff and

technical support staff. Brought Medicare subject matter

expertise and knowledge Analyze and solve problems in

order to recognize trends or anomalies.

. Data Collection: Identifying appropriate reconciliation

process to resolve data discrepancy and collection

appropriate data to submit and resolve discrepancy.

Analyzing internal plan enrollment data and submissions

to CMS against membership data received from CMS.

Reviewing special status processes to ensure all

submissions are accepted and processed requirements to

projects.

. Accurately. Data Analysis of enrollment/eligibility files

to ensure all members are setup as requested with the

correct group account, benefit package, and rates. Focus

on data analysis specifically related to identifying

members with data and payments discrepancies between the

plan and CMS (Medicare).

. Billing/Collections: Determined the root cause of any

variance in billing and prepare Discrepancy reports for

external customers. Managed all facets of account billing

and reconciliation for Medicare enrollees for Horizon

Blue Cross Blue Shield of NJ. Determined the root cause

of any variance in billing and prepare Discrepancy

reports for external customers. Maintained and provided

monthly status reports for management review. Processed

billing/payment adjustment due to retroactive enrollment

transactions. Ensured the accurate and timely application

of group and non- group premium payments. Reviewed Aging

Reports each month and processed adjustments as needed.

Processed Direct Pay adjustment.

. Customer Service: Managed the resolution of customer

issues and requests regarding accounts, refunds, billing

discrepancies and services performed. Inbound and

outbound collections and customer service calls. Taking

telephonic attestation to ensure member had creditable

coverage prior to enrollment into Horizon's Medicare.

Processing LEP (Late Enrollment Penalty) and the appeals

of the LEP through Maximus, Medicare's appeals process.

. Healthcare Patient Financial service.

. Healthcare revenue cycle (premium reconciliation and

collections)

. Special Projects: Assisting with the initial set up of

the delinquency process for member enrolled in a Medicare

product through Horizon. Preparing Cases for Medicare

Audit

02/2003 to 10/2010 DEPARTMENT OF VETERANS AFFAIRS Lyons, NJ

Reconciliation Analyst with Business Analyst Functions

. Duties included all phases of accounts receivables for a

federal medical facility with Business Analyst functions.

. Business Structure Analysis: Supported business

initiative through data analysis. Identified

implementation barriers. UAT Testing of various systems.

Identified and analyzed Business Office requirements,

procedures, and problems to improve existing processes.

Preformed detailed analysis on multiple projects,

recommended potential business solutions to ensure

successful implementation. Diagnosed problems and

Identified opportunities for process redesign

improvement.

. Healthcare Patient Financial service.

. Healthcare revenue cycle

. Collections: included collections calls to patients to

collect all self-payments due. Follow up collections from

insurance carries in order of high balances and aging.

Daily required productivity was 75 collection calls. Also

made collection calls from an automatic dialer system the

daily requirements for the dialer was 80 calls a day.

. Book keeping: included writing off old balances, credit

balances, patient insurance carrier's refunds, referring

aged debt to legal counsel for garnishment. We also

offered hardships, waivers, and settlement offers to help

our patients handle the cost of medical services and

prescriptions.

. Electronic Billing/Collections; EDI 835/837 transactions,

included posting payments from remittance advice and

appealing denials. Billing both professional and facility

claim focus on data analysis specifically related to

identifying members with data and payments discrepancies

between the plan and CMS (Medicare). Also billing

prescription claims.

. Reports creations/ Analyzing; included creating days,

week, and month, yearend reports to show what we

collected and what we still need to collect to reach our

monthly goal. These reports also show details of problem

areas and strong collections points and to show

productivity of each medical professional and clinic.

Also included analytical review of the age trail report

shows the lack of payment or denial from both the

insurance carrier and the patient. It is also is used to

targets problem areas with specific carriers.

. Analyze and solve problems in order to recognize trends

or anomalies

. Patient Billing inquiries: includes customer call and

mail correspondence in regard to their bills and claims

submitted to their carriers. Disputes and multiple claims

submissions done in error

. General office; included data entry, faxing, coping,

sending /receiving email, creating spread sheets,

reports, payment posting to individual accounts, and

daily bank deposits.

. Insurance Verification; included calling each patient's

insurance and document all aspects of their individual

plans guidelines. Also, to obtain referrals and pre-

certify all needed procedures.

. Claim submission; included no fault, personal injury, and

workers compensation billing. Also billing commercial

insurance claims, Medicare and Medicaid. Special billing

to research grants for specific illnesses like cancer or

diabetes. Claims are submitted both electronically and

hard copy for prescriptions, dental, vision, mental

health, and general medical.

578 Buchanan Street, Hillside, New Jersey 07205 973-***-****

****************@*****.***

. Strong knowledge in the areas of Healthcare Industry as a

Reconciliation Analyst for Medicaid and Medicare

Enrollments.

. Proficient to audit accounts records (i.e. income

schedules, write-off, schedule checks, etc.) to verify the

proper recording of transaction and to reconcile group

and/or Plan billing records.

. Strong Knowledge Medicare Advantage

. Strong Knowledge Medicare Secondary Payer for Non-GHP.

. Proficient in all phases of accounts receivables for a

federal medical facility.

. Proficient with billing and collections on commercial, HMO

also Medicare and Medicaid and Post Charges and payments as

well as Electronic Billing.

. Proficient creator of corrective plans, data analysis,

developing training tools.

. Proficient with NASCO, IKA Medicare Gateway, Regression

systems for Billing, Collections, Claims, Provider files

and Medicare enrollment/servicing.

. Working Knowledge of Facets for Billing, Collections,

Claims and Providers files.

. Strong knowledge of federal and state laws regarding

Medicare and Medicaid Services

. Proficient in Microsoft Word Excel, Outlook, PowerPoint,

Access, Data Entry and the Internet

. Proficient in Medicare enrollment through a local insurance

carrier and assessing any potential gaps in coverage.

. Proficient with adherence to timeliness in accordance to

CMS (Centers for Medicare and Medicaid Services) guideline

. Proficient in Date Mapping and Validation

. Proficient with HIPAA, EDI 835/837,4010 and 5010 with ICD-9

and ICD-10, analysis & compliance experience from, payers,

providers and exchanges perspective, with primary focus on

Coordination of Benefits.

. Proficient at conducting a Requirement Analysis and

documentation, creating corrective plans, UAT testing and

creating work flows with IT support team.

Contact this candidate