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Claims Data Analytics Health Insurance Data Analytics

Denver, Colorado, United States
February 19, 2018

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Todd A. Wilson


** ***** ****** ********* **********: claims, Medicare, Medicaid, employer-offered/sponsored benefits and analytics:

* Self-funded, ASO, partially self-funded, fully insured

* Medicare, Medicare Advantage, Medicaid, Medicaid HMO, Commercial, Dental, FSA Section 125, Vision, STD, LTD, Rx, Reinsurance

* 7 years claims data analytics; Medicare, Medicare Advantage, Medicaid, Commercial plans

* Consulting/Analytics; national insurance carriers & their claims systems, claims data, over payment & incorrect claim payment identification & root cause analysis

* Consulting/Analytics; Client facing - high-level executives, departmental heads, leads & staff. Internal executives, project managers, leads & colleagues

* 17 years claims adjudication: medical, dental, vision, FSA, Rx, claims investigations, claims supervisor, subrogation claims supervisor, appeals/grievance resolution, customer service

* Plan Design: SPD, MPD negotiation, analysis, configuration, administration & implementation

* 5+ years provider-side billing focusing on high-dollar, 1st time clean claim submission

* Fluent on 12 national carriers’ claims platforms including Facets, CS90, OSCAR, MHS, PowerStepp, RiMS, EPIC

* RFP, market bid analysis and employer presentation for: medical, dental, vision, EAP, reinsurance, Rx; existing plans, new plans, renewals; presentation & delivery

* Plan negotiations between client/employer and major insurance carriers, all lines of employer-offered benefits including Rx

* Fluent: Federal, State & Commercial Industry standards

* Fluent: CPT & modifiers, ICD-9, ICD-10, HCPCS, CMS-1500, UB04

* Fluent: High-level contracting; PPO, EPO, HMO, POS, HDHP, HSA, HRA, Indemnity, Capitated, CMS & state

* Fluent: provider relations & contracting

* Large case management

* Risk pool management, ICD shock reporting for reinsurance purposes

* 5 benefits/claims software conversions: many levels of involvement from simple support to deep-dive matrix, mapping, acquiring necessities for customizing benefits/claims platform conversions (up to a 2 year process)

* Resident claims SME for entire employer benefits brokerage. Claims resolution for employer/client employees

* Employee open-enrollment preparation, logistics, presentations

* 7 years consulting, deep-dive analytics into commercial (self-funded & fully insured), state & federally offered medical plans

* UAT; systems, applications

* Fluent on 12, national carriers’, benefits administration & adjudication software platforms

* If not fluent, am a quick-learner and highly adaptable to benefits software/platforms

* SME on all aspects of coordination of benefits (COB) for medical & dental plans; Federal (Medicare, Medicare Advantage, TriCare), State & Commercial; NAIC fluent


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