Resume

Sign in

Customer Service Manager

Location:
Washington, District of Columbia, United States
Posted:
June 04, 2019

Contact this candidate

Resume:

Maggie Shepard

email: ac9i8k@r.postjobfree.com

Cell: 202-***-**** Home: 202-***-****

Professional Experience

Business Analyst - BlueCross/BlueShield Association, Washington, DC

April 2018 to November 2018 (Contractor)

Facilitate in requirements elicitation meetings with business stakeholders and other project team members to identify and define business needs and objectives for varied projects.

Created mockups to document current AS-IS into TO-BE requirements.

Scheduled Peer Review meetings to review draft requirements updates/and or changes prior to sign -off and approval of requirements.

Translate business needs into effective functional/ Non-functional and technical business requirements for Waterfall and Agile projects using Scrum sprints.

Provide support to the technical and product verification team during the life cycle, ensuring approved business requirements are documented by the teams.

Managed requirements in Requirements Management Tool (HP ALM) and created (RTM) Requirements Traceability Matrix for all requirements managed in HP ALM and status of any defects.

Contract Analyst - Health Care Insurance, The Advisory Board, Washington, DC

May 2017 to March 2018

Analyze, interpret and load hospital contract data into the Payment Integrity Compass system.

Provide analysis in validating payer contract reimbursement against PIC system calculations using patient accounting data.

Create/process Institutional and Professional contract terms in PIC for Commercial, Medicare, Medicaid, and Tricare systems.

Research new calculation methodologies, contract reimbursement terms and payment formulas on CMS website, and mandates for individual States

Provide functional client support via phone, e-mail and internal chat related to Medicare Fee- For- Schedules loads or DRG versions, etc.

Perform UAT and Post-implementation, update and maintain existing client contracts to include new or revised terms.

Senior Business Analyst, CareFirst, Washington, DC

August 2015 to April 2016 (Contractor)

Medicare Edit Project

Re-created and processed Outpatient facility and Professional claims in FEPDirect for Master File Edit FEM.

Drafted acceptance criteria for user stories to clarify stakeholders and business needs on the Medicare Edits for Waterfall and Agile projects using Scrum sprints.

Created new member contract IDs via the enrollment tab for Medicare 65 and under/over 65 members.

Provided project status report at the weekly Project Management meeting to the team.

Preformed Gap Analysis on the FEM edit for Medicare 65 and under members.

Enhancements to Claims Audit Monitoring Tool (CAMT) Release 2

Gathered business requirements and broke them down to relevant, accurate and detailed functional and non-functional requirements and user stories.

Facilitated status meetings with business stakeholders, testing and development teams for Waterfall and Agile projects using Scrum sprints.

Baselined Requirements and created the (RTM) Requirements Traceability Matrix in HP ALM.

Reviewed unit tests and quality assurance test cases to ensure coverage of all relevant business scenarios.

Participated in requirements and test case peer reviews.

Updated functional/non-functional requirements based on stakeholder feedback during JAD sessions.

Prepared all meeting agendas, notes, issues, action items and sign-off approvals.

Maintained and updated all project related artifacts via SharePoint.

Quality/Requirements Analyst, CareFirst, Owings Mills, MD

October 2012 to August 2015

Maintained Enterprise Requirements Management process methodology to ensure requirements accuracy.

Managed the requirements and implementation of multiple project phases of quality reporting dashboard development for Waterfall and Agile projects.

Validated business requirements for importing into HP Application Lifecycle Management (ALM).

Interpreted requirements and built test cases using Software Development Life Cycle (SDLC).

Ensured test cases linked to the appropriate Functional requirements prior to signing off to the Testing team.

Completed SDLC documents such as Baselining and (RTM) Requirements Traceability Matrix, etc.

Created new project folders for various project teams in HP Application Lifecycle Management (ALM).

Attended and reported project teams’ requirements status at the Weekly Schedule Review Committee (SRC) meetings.

Engineer/ Software Testing Lead, CareFirst, Owings Mills, MD

January 2010 to October 2012

Tracked defects related to testing of new and or modified provider contractual (agreements) via HP Application Lifecycle Management (ALM) for Waterfall and Agile projects.

Created Test Cases (As is/To Be) to include expected and actual results.

Served as Test Lead on various projects, including Electronic Health Records (EHR).

Developed test plans, estimation budgets and project schedules.

Provided weekly reports on Defects, Test Cases Performed and issues related to the provider domain.

Performed testing of new or modified provider contracts for Fee-schedule accuracy for Professional/Institutional claims via UAT as well as Regression testing.

Trained/mentored team members on creating new test cases for validation using FACETS and Networks Pricer.

Validated Member benefits vs Provider Contracts during claims adjudication process via Test cases.

Test Manager, CareFirst, Owings Mills, MD

June 2009 to December 2009

Tracked defects related to testing of new and or modified provider contracts (agreements) via HP Application Lifecycle Management (ALM) for Waterfall and Agile projects.

Attended cross-functional meetings regarding reported defects in the provider domain using FACETS.

Worked with Vendors regarding defects reported during UAT and Regression testing.

Performed testing of modified provider Fee-Schedules for the accuracy of pricing Professional and Institutional claims via UAT and Regression testing.

Created and tested cases on EFT (Electronic Funds Transfer) for 835 claims.

Created and tested cases for Enrollment transactions for 834 related maintenance.

Tracked defects related to testing of PEGA upgrades.

Consultant, STAR Consulting Services, Contractor for short-term business development project, Washington, DC October 2008 to June 2009

Assisted with developing business cases and lead generation for potential healthcare projects.

Provider Configuration Analyst, Kaiser Permanente, Silver Spring, MD

September 2007 to September 2008

Responsible for system design, analysis and input of contract information into DIAMOND, the host processing (and other) systems, for proper payment to Facility and Professional providers etc.

Analyzed provider contracts to determine the best approach for loading DRG, Fee- Schedule schedules

into the Claims Processing Tools DIAMOND and Amisys.

Determined if new/or amended Fee Schedules/Pricing rules required new benefits rules logic to support claims adjudication.

Built the logic in DIAMOND, Amisys and other systems to support provider contracts and Member Benefits.

Developed and executed test templates for configuration testing and to validate data accuracy.

Performed problem resolution of configuration issues and documented results for the repository.

Ensured the deliverables produced met quality, cost, and timely standards in accordance with applicable federal, state, and local laws and regulations for multiple regions.

Claims Recovery Specialist, Kaiser Permanente, Silver Spring, MD

December 2004 to September 2007

Recovered claims overpayments identified through audits, using Claims Administration Recovery System database (CARS) during Post Payment review.

Presented findings to the Provider Relations, Contracting and Legal department prepared recovery evidence supporting recovery requests.

Performed special projects related to claims processing improvement.

Performed root cause analysis and designed corrective actions to prevent overpayments.

Recovered $500-$1,000,000 in overpayments per month.

Claims Resolutions Specialist, Kaiser Permanente, Silver Spring, MD

October 2002 to December 2004

Performed analysis and resolution of complex claims payment issues using DIAMOND the claims processing tool.

Served as expert member of self-directed improvement team for adjustments and account resolution.

Reviewed provider contracts to validate issuance of correct payments vs Member’s benefits.

Initiated recovery opportunities discovered in the day-to-day activities of the department.

Facilitated resolution between Claims, Provider Relations, and Provider Contracting.

Analyzed complex, business sensitive payment issues and inquiries.

Audited Claims department processes, Post claims adjudication via DIAMOND.

Developed better communications with the provider contracting department.

Customer Support Manager, CF Services Pharmacy, Inc., Bethesda, MD

January 2002 to September 2002

Managed 6-person Customer Call Center for a retail pharmacy.

Upgraded customer support procedures to ensure responsive, high quality service.

Monitored and reported service performance; resolved outstanding issues.

Provided expert level tier 1 and 2 product technical support.

Maintained ongoing accuracy of key service databases.

Responsible for initial, ongoing, and crossing-training for customer service center staff.

Prepared call center scripts for customer service staff.

Used technologies to improve the customer services and overall customer satisfaction.

Improved services offered and customer satisfaction ratings by 30%.

Quality Assurance Consultant, HTH Worldwide Insurance Services, Fairfax, VA

July 2001 to March 2003

Generated productivity reports and quality assurance reports.

Performed weekly, monthly and quarterly claim audits for 10 examiners.

Ensured claims department was able to meet the regulatory requirements for quality.

Updated and trained staff on QA policies and procedures.

Briefed senior management on continuous QA improvements.

Claims Manager, American Preferred Provider Plan Mid-Atlantic, Inc., Washington, DC

October 1997 to March 2001

Planned, organized, and delegated claims workflow for this Medicaid MCO.

Supervised operations, training, and coaching to improve performance.

Ensured claims department met regulatory requirements for quality.

Performed weekly claims audits and resolved problems of eligibility or benefits.

Reviewed and upgraded cost control measures and accounting-related issues.

Trained staff in new policies and procedures concerning claims.

Completed all HEDIS measures reporting for the Medicaid population

Used SQL queries to complete Claims data analysis for each specific measures

System administrator for troubleshooting and resolving problems relating to hardware and software issues. Responsible for liaison with software and hardware suppliers.

Results: Improved trend reporting; developed office manual for claims processing; served on appeals committee to handle members’ and providers’ disputes.

IT Skills

Software: Microsoft Excel, AdHoc Reporting, Access, ServiceNow

CareFirst Applications: HP Application Lifecycle Management (ALM), Quick Test Pro (QTP), NetWorx Pricer, FACETS, Clarity, Claims Audit Monitoring Tool (CAMT) and FEPDirect

Kaiser Permanente Software Applications: Diamond, Kmate, Pega, Pace, MASK, Amisys, MC400, FACETS, and Claims Administration Recovery System database (CARS)

Advisory Board Applications: Payment Integrity Compass(PIC)

Certification:

Six Sigma Certification, 2013

Education

Bachelors of Science Healthcare Administration, Washington Adventist University, Takoma, Park, MD

MBA/BS, Washington Adventist University, Takoma, Park, MD



Contact this candidate