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HEDIS Coordinator

Location:
Richmond County, New York, United States
Posted:
April 24, 2018

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Resume:

Thomas O'Shaughnessy

ac48ok@r.postjobfree.com 646-***-**** Staten Island, NY 10309

Project leader with experience coordinating and leading teams within the health insurance data sector. Demonstrated ability to strategically assign team tasks towards individual strengths with the objective of meeting project goals and timelines. Knowledge of health insurance industry, provider networks, and state and federal regulations for health information confidentiality. Proven results establishing strong relationships with providers, staff, and internal departments. Collaborative approach to resolving issues and improving processes and procedures. Strong training and facilitation skills.

Areas of Expertise include:

HEDIS Coordination

Medical Terminology

Electronic Medical Records

Insurance Data Regulations

Team Supervision

Training/Coaching Performance

Project Coordination

Process Improvement

Professional Experience

Anthem/Amerigroup • Iselin, NJ

HEDIS COORDINATOR, September 2016 to December 2017

Manage HEDIS quality improvement efforts for the Medicare East Region section of a major health insurance provider. Coordinate medical record and abstraction processes and projects. Supervise daily work of collection staff and temporary clerical workers. Request chart information from provider offices. Identify trends for the Medicare enrolled population, provide recommendations, and implement changes related to the use of HEDIS data. Develop training manuals, templates, and procedures. Comply with and maintain HIPAA standards in all aspects of handling health information data.

MEDICAL HEALTH PROGRAMS REPRESENTATIVE, 2014 to 2016

Contacted members to explain benefits and process enrollments for preventative healthcare and disease management programs. Conducted interviews in person and via phone to determine patient needs. Identified preventative screening options and presented information to members. Contacted physician offices for medical records requests. Maintained confidentiality of patient information and ensured proper documentation for patient charts, admissions, and consent forms.

Horizon Blue Cross Blue Shield of New Jersey • Newark, NJ

PROVIDER NETWORK SPECIALIST, 2012 to 2013

Liaised between providers and health plans to enhance the provider network. Established and maintained strong relationships with providers, staff, and internal departments. Served as a primary contact for providers to resolve issues and maintain account information. Educated providers on policies and procedures for referrals, claims submissions, and credentialing documentation. Reviewed quality and financial results and provided information to improve outcomes within the provider network.

PHYSICIAN SERVICES LIAISON, 2010 to 2012

Oversaw the referral network for the state of New Jersey. Reviewed, analyzed, and identified trends in physician referral patterns and financial margins. Recommended sales resources to optimize referrals. Partnered with internal departments to prioritize and resolve areas identified on field visits. Maintained knowledge and expertise of service lines and related products.

CLAIMS INVESTIGATOR, 2007 to 2010

Conducted analysis of claim data and medical coding practices for Commercial accounts. Reviewed data to ensure compliance with internal guidelines and state regulations. Served as a Team Leader and subject matter expert to resolve errors with claims submissions. Supervised, coordinated, and monitored team tasks and performance. Provided technical training and coaching to improve team results. Resolved complex issues with errors and reconciliations.

ACCOUNTS RECEIVABLE REPRESENTATIVE, 2006 to 2007

Followed up and resolved issues with negative adjustments on claims. Researched billing and account information, determined where funds were applied, and communicated with provider offices to resolve issues. Processed benefits and claims for Hematology and Oncology providers in New Jersey.

Additional experience:

Call Center Associate – Horizon Blue Cross Blue Shield of New Jersey

Regional Marketing Manager – Foxton’s

Account Officer – T. D. Waterhouse

Customer Service Specialist – Trade.com

Education & Certifications

Medical Billing and Coding Specialist – AIHMA CCS

New York City College of Technology - Continuing Studies Center

LeMoyne College -- Business Management

Certificate in Culinary Arts,

New York Restaurant School • New York, NY



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