Judeth A Dwyer, CPMA

Providence, RI *****

***- ***-**** • ac3i2k@r.postjobfree.com

PROFILE

Decisive and results-driven professional with the ability to consistently leverage strategic planning, management and critical thinking skills to lead successful change-management initiatives. Definitive leadership and business process analysis competencies have contributed to notable productivity enhancements and mitigated cost exposure for prominent health insurance organizations.

Areas of Effectiveness

• Performance Management • Call Center Staff Development

• Claims Processing and Workflow Planning • Compliance Monitoring and Quality Assurance

• Team Leadership and Guidance • Business Process Reengineering

Able to effectively drive and guide staff performance by employing a management style that emphasizes supportive team leadership, ongoing motivation and shared responsibility for working toward quality and productivity goals.

Innovative in the design of creative solutions to emerging problems. Adept at interfacing with individuals at all organizational levels to maintain the alignment of collaborative efforts.

PROFESSIONAL EXPERIENCE

BlueCross Blue Shield of Rhode Island, Providence, Rhode Island 2013 to 2016

Facets Configuration Analyst

Analyze and assess business requirements by interpreting and translating into system configuration solutions.

Assist in Proof of Concept testing within Facets.

Document, design, build and test configuration in support of business requirements for Medicare and Commercial business.

Participate in functional specification and design reviews, validating configuration aspects.

Work with tables and data models using various tools to extract and assess data, applying best practice solution

to analyze and configure business requirements.

Generate clear and concise documentation and communicate effectively to customers and management.

Reviewed auto-adjudication of claims that resulted in paused claims due to established Workflow rules. Worked with Claims area to educate how claims would be released.

Participated in a weekly group reviewing migrations, batches and platform upgrades.

Reliance Systems, Wellesley, Massachusetts

BlueCross Blue Shield of Rhode Island Account 2012 to 2013

Consultant

Performing as a Quality Assurance tester for the ICD-10, HIPAA and PBM, (Pharmacy Manager), projects.

Claims testing for Medicare and Commercial lines of business for both Facets and Legacy processing systems.

Participated in the company’s Corrective Action Plan for the Medicare line of business.

Joined in multiple initiatives involving the upgrade and compliance of the ICD-10 implementation. This included, but is not limited to; BHS Compliance, 3M Grouper Upgrade, Encoder Pro Compliance, PFEX Replacement, HLI Boxi Reporting and Data Oceans Compliance.

Met with Business Analysts concerning BRD’s written for departments monitoring their ICD-10 compliance such as; Medical Management, Provider Management, Medicare, NEPH, ITS and FEP. From these meetings, test cases were written based on the requirements stated in the documentation.

Identified much of the needed documentation and stored in Sharepoint.

Utilized HP Quality Center to house test scenarios. Also used this tool to execute test cases and track defects found as a result of the completed testing.

Called upon to assist with the Medicare Corrective Action plan for BCBSRI. Updated work processes based on CMS guidelines, instituted Quality Assurance guidelines and worked with Dell Health Services to implement.

Perot Systems Healthcare, Providence, Rhode Island

BlueCross Blue Shield of Rhode Island Account 2004 to 2009

Manager

Lead and mentored a team responsible for Basic and ITS Business priority projects, Customer Call Center operations and inquiries.

Acted as HIPAA compliance liason, providing customer support regarding possible claims and inquiry infractions.

Identify and implement business process enhancements and increased automation that resulted in significant cost reductions and measurable improvements in service delivery, quality and productivity.

●Participated in a tenfold reduction with a significant inquiry backlog by identifying the processes needed to improve cycle time and by instituting product/service quality improvement practices.

●Identified and capitalized on opportunities to strategically integrate offshore outsourcing into the existing business model to mitigate corporate cost exposure.

●Provided business process enhancements that resulted in significant cost reductions and measurable improvements in service delivery, quality and productivity.

●Participated in vendor business opportunities to outsource aspects of managed care for prescription drugs to reduce operating costs.

●Participated in the configuration, enhancements and documentation to support system replacement on the Blue Cross & Blue Shield of RI Account.

●Coordinated internal and external audits inclusive of CMS and SAS.

Perot SystemsHeathcare, Providence, Rhode Island

BlueCross Blue Shield of Rhode Island Account 2003 to 2004

Supervisor

●Guided team through operational changes resulting from vendor transition.

●Assisted with user acceptance testing to ensure implementations resulting in zero defects.

●Interfaced with the Business customer to identify requirements for system enhancements that resulted in efficient claims processing.

●Participated in an Operational Efficiency Team focused on a partnership with internal Business Customer.

●Identified best practice solutions resulting from participating in Business Process Reengineering.

●Teamed with members of department management to assist the vendor in the configuration of the Macess replacement system.

●Instrumental in the updating of workflows necessary to meeting customer satisfaction as a result of vendor enhancements.

●Performed time studies of unit tasks to ensure proper quality and time effectiveness.

●Designed updated educational manuals and implemented department training to guarantee service quality and productivity.

●Coached staff regarding claims processing/adjustment methodologies and benefit information.

●Participated in the implementation of internal audit and recovery reviews that supported business cost reductions.

●Responded to provider and customer telephonic and written inquiries regarding claims and settlement issues.

●Provided direct troubleshooting and educational assistance to providers in-house and on-site.

●Contributed to the success of the unit through training and mentoring of new staff.

●Coordinated appeal reviews, corresponding with providers regarding final determinations.

●Assisted management with reporting that aided in meeting EAQA timeliness goals.

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EDUCATION

Community College of Rhode Island, Warwick, RI

Associates Degree, Liberal Arts

Medical Office Alternatives, LLC

Certified Professional Coder (CPC) Course

Certified Professional Medical Auditor (CPMA) Course

CERTIFICATIONS/MEMBERSHIPS

AAPC Member 2016

Certified Professional Medical Auditor 2016

Facets Certification 2014

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