Benefit Configuration Analyst

Marissa Shaiek

**** *. ****** ***** *****, Glendale, AZ 85304 – 602-***-**** – *********@*****.***

EXECUTIVE SUMMARY

Over Twenty years in Healthcare insurance, billing, and customer services with a current back ground of claims testing and auditing. Proficient in creating spreadsheets, auditing and maintaining data information, along with experience with claims processing, coordination of benefits and explanation of benefits. Capable of working under minimal supervision. Bilingual speaking, able to learn quickly and perform accurately. Received many awards throughout career for excellent team work and going above and beyond. Approaches every position held with a positive attitude and energy. Enjoys being pushed and challenged, as well as handling multiple tasks.

OBJECTIVE

Determined to obtain a position that will be challenging as well as rewarding. Experienced in research as well as analyzing data. Motivated and willing to learn what it takes to perform any task given

QUALIFICATIONS

• Twenty years of experience within the health insurance industry

•Twenty years of experience within an office environment

•Proficient with all Microsoft office products

•Quick learner with amazing multi-tasking skills

•Well organized and detail oriented

•Time / workload Management

•Ability to work independently / Telecommute Experience

•Excellent under pressure

•Problem Solver

•Team player

•Analysis / Research

•Strong oral and written communication skills

•Knowledgeable in Medicare and Medicaid

•CMS / DRG processing

•Hospital and Medical Claims processing

•Expert Data Entry Skills

•Quality Analysis

•Project Experience

TECHNICAL SKILLS

• Microsoft Word / Excel / PowerPoint/ Outlook / SharePoint

•SQL Server / Sybase /

•Facets –

•User Acceptance Testing for the Configuration team

•Read the contracts loaded into Facets by configuration

•Create new claims for testing purposes

•Review the configuration criteria for testing purposes to validate that the correct configuration is being tested. IE: correct provider type, using the valid codes from the contract, verifying rates are applied correctly as well as benefits.

•Navigate through Facets easily

•Diamond Claim Platforms

•Company based programs

•Knowledge of RECAP

•RXClaim

•PeopleSafe Platform

•Answering Phones and other general office tasks

•Ability to read and interpret all types of provider contracts in order to update claim systems properly per benefits and rates.

EDUCATION

Gateway Community College 1/2002

CPT/ICD-9 Coding Courses

Phoenix, Arizona

University of Phoenix 11/2000

A+ Certification Computer Course

Phoenix, AZ

S.W. School of Business and Administrative Skills 09/1995

Vocational/Technical Certificate

Eagle Pass, Texas

Eagle Pass High School 05/1994

Graduated

Eagle Pass, Texas

WORK EXPERIENCE

Benefit Configuration Analyst/QA 01/2012 – 11/2018

United Healthcare

Phoenix, AZ

•Performed various analysis and interpretation to link business needs and objectives for assigned function

•Support business initiatives through data analysis, identification of implementation barriers and user acceptance testing of new systems

•Identified and analyzed user requirements, procedures, and problems to improve existing processes

•Identify ways to enhance performance management and operational reports related to new business implementation processes

•Develop and incorporate organizational best practices into business applications

•Problem solving and coordination efforts between various business units

•Assist with formulating and updating departmental policies and procedures

•Resolve issues and identify opportunities for process redesign and improvement

•Assesses and interprets intent of institutional and physician contracts to determine system configuration accuracy.

•Created and executed standard, repeatable test protocols to ensure configuration accuracy

•Works with team leads; Assist with complex tasks and projects

•Translates concepts into practice

•Maintains SOX-compliant documentation, including testing outcomes, defects, risks, change controls, issues, and decisions

•Executes and analyzes reports/data to verify the accuracy of system configuration against contract intent and claim payment trends.

•CQM partners, participates in meetings and conferences calls with internal department customers

•Presents testing results and information to internal department customers.

•Ensures that system configuration adheres to Medicare, Medicaid, and other federal/state regulations.

•Monitors inventory controls, provides status reports for assigned projects.

•Continually improves test script design to ensure that system support tables, interfaces, third party pricing tools, provider contracts, and member benefit packages are configured properly to pay claims and apply benefits for our members/providers.

•Audited claims to validate accuracy

•Adjusted claims that were found to be inaccurate

•Tracked and reported trends through claims projects received on excel grids

•Complex high dollar claim processor / CMS-DRG

•Provided feedback to claim processors if processor error was found

•Test claims processing

•Evaluate concerns and communicate to management

Reimbursement Specialist 10/2011 – 012/2011

McKesson

Scottsdale, AZ

Responsible for reviews and audit claims that are processed incorrectly per Caremark and CMS Guidelines

Reconciliation of Medicare D benefits

Complete tasks in a timely manner and accurately

Worked directly with other co-workers, supervisors and claims adjusters to achieve results

Subject Matter Expert of Medicare D benefit structure and reconciliation

Was part of a special team that focused on large scale claims projects

Reconcillation Analyst 05/2007 – 08/2011

CVS Caremark

Scottsdale, AZ

Responsible for reviews and audit claims that are processed incorrectly per Caremark and CMS Guidelines

Reconciliation of Medicare D benefits

Complete tasks in a timely manner and accurately

Worked directly with other co-workers, supervisors and claims adjusters to achieve results

Subject Matter Expert of Medicare D benefit structure and reconciliation

Was part of a special team that focused on large scale claims projects

Patient Financial Advisor/Collector 02/1999 – 05/2007

Mayo Clinic Arizona

Scottsdale, AZ

Patient Liaisons for international patients

Interpreter

Analyzed collections reports and worked on settling outstanding collections accounts

Reviewed and prepared analytical reports in order to submit non-payment accounts to an outside collection agency

Review and audit outstanding patient accounts.

Met with patients to review and audit their accounts in order to determine if maximum insurance payments were issued.

Investigated reasons claims were paid inaccurately either by system or human error

Maintained billing database for pricing, along with updated policies, forms and work flows

Answered patients complaints and questions regarding billing and insurance

Financial assistance liaisons. Assisted patients will finding the right good will/charity program to be able to cover medical expenses

Patient Services / Referral Coordinator 01/1998 – 03/1999

Biltmore Cardiology

Phoenix, AZ

Interpreter

Insurance verification

Prior authorization approvals

Surgery scheduling

Interpret provider contracts in order to renew our cardiologist credentials

Front end/Back end, schedule appointments, follow-up visits, cancellations, reschedules

Patient Liaison for surgery and procedure scheduling

Investigated reasons claims were paid inaccurately either by system or human error

Billing and reprocessing of denied claims

Maintained monthly contracts for senior citizen cardiology programs

Patient Services 01/1996 – 01/1998

Glendale Family Practice

Glendale Heights, IL

Interpreter

Insurance verification

Prior authorization approvals

Surgery scheduling

Front end/Back end

Patient Liaison for procedure scheduling

Traveled between medical offices in order to translate for our physicians with their patients

References upon request

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