Customer Service Quality Assurance

Ann-Marie M. Brown

*** **** ***** ****

Plymouth Meeting, PA 19462

215-***-**** (Work) or 610-***-**** (Cell)

Email: ********@*****.***

OBJECTIVE: To obtain a position that will allow me to utilize my extensive

business knowledge in the healthcare, claims and insurance

industries.

EDUCATION:

Gwynedd-Mercy College, Gwynedd Valley, PA

o Bachelor of Science, Cum Laude, Computer Information Science,

2000.

Member of the Gwynedd-Mercy College Montgomery County AITP and Alpha

Sigma Lambda Honor Society.

o Bachelor of Science, Magna Cum Laude, Business Administration, 1988,

Concentrations in Marketing and Finance.

Montgomery County Community College, Blue Bell, PA

o Associate of General Studies, 1986, Concentrations in Education

and Business.

WORK EXPERIENCE:

Aetna, Inc., Blue Bell, PA

OA Senior Consultant, ASO SS OACC Supplier Quality Audit Department,

04/2014-Present

o Tasked with setting up department to ensure state and federal

regulations, contractual obligations and company policies are met by the

vendors supplying overpayment recovery activities. This includes

selecting the various reports to audit as well as the criteria each

report will encompass from an audit standpoint.

o Developed a Scorecard for each of the Suppliers illustrating strengths

and weaknesses.

o Set the goals and standards the Suppliers need to meet.

o Perform weekly audits on reports of claims adjudicated in the ACAS Claims

system when the amount being retracted from a provider is not equal to

the amount in the OverPayment Tracking (OPT) database.

o Perform monthly audits on the Suppliers cases that are in an Open status,

Pend status, cases in OPT lacking the proper authorization for Reversals,

Write-Offs and Non-Pursuits as well as NSF Checks that need replacing and

commissions refunded.

o Perform quarterly Compliance audits verifying all state legislation

regulations are met, reviewing copies of the letters sent to the

providers requesting refunds along with all supporting correspondence,

verifying OPT for accuracy and the HMO and ACAS Claims systems have been

set-up correctly with the reasons for the overpayment and actual

refunding/minus debiting of the overpayments themselves.

Senior Consultant, Subrogation, Workers Compensation and COB Cost

Containment Department, 2013-2014

o Obtained Security Access for the department's vendor constituents by

adding them to the company's Human Resource system using PeopleSoft and

obtaining an Aetna ID Number. Requested access to mainframe, web based

applications and proprietary applications. Troubleshot system access

issues.

o Was responsible for over 350 direct reports that needed to be advised of

Learning Center Courses required to retain various accesses, needed to

confirm contract extensions and terminate all access when an employee was

no longer performing duties for Aetna.

o Received and disseminated requests from vendor attorneys and managers

working subrogation cases to have unpaid claims processed for payment so

the maximum refund could be obtained. Researched claims on both the ACAS

and HMO systems to determine if claims were eligible for reprocessing and

payment utilizing ASD, HMO Claims System, CLI, ECHS and EWMP as well as

Plan Sponsor Tools for research.

o Security Access Resource Coordinator for over 200 additional users. This

included obtaining initial access, requesting changes due to position

changes and assisting vendors when they had problems surrounding access

for both individuals and the group.

o Obtained access to vendors' websites for all Aetna and constituent

employees.

o Received the Peer Recognition award for exceptional service.

Senior Consultant, Cash Handling and Transactional Control Department, 2009-

2013

o Evaluated and approved access for the OverPayment Tracking (OPT)

application. Was primary person responsible for vendors' access in OPT.

This was a company-wide enterprise that required manual approval.

Confirmed there were no security issues or conflicts with the addition of

access to the OPT database for both on-shore and off-shore personnel.

o Applied funds received from vendors for overpaid HMO claims including

updating mainframe, appropriate databases and reports.

o Security Access Resource Coordinator for over 500 users. Obtained

initial access, changes and assisted with access issues.

o Answered questions regarding vendor refund checks, wires and minus debits

on claims.

o Re-worked claims for special projects involving claims previously minus

debited in error by the suppliers.

o Assisted in the transition and creation of new RBACs on Citrix/ECAN for

the suppliers when preparing for OPT to go live. This involved twelve

companies, over five hundred individuals being moved and

compliance/security issues having to be met at each step. Everyone was

moved manually requiring extensive coordination to avoid loss of

productivity and system downtime.

o Conducted several classes to assist co-workers with Excel and showed

strategies to work smarter not harder.

o Nominated for the Peer Recognition award for service to the department

three times, winning twice.

Senior Consultant, NCO Overpayments Department, 2003-2009

o Performed daily and monthly financial reports consisting of recovery

efforts for HMO and Medical Economics Units.

o Was the primary Security Access Resource Coordinator for the National

Customer Organization's Overpayments and Vendors Overpayment Departments.

o Maintained RBACs for the vendors working with the Overpayments

Department. Ensured there were no security issues with regards to system

access.

o Re-processed claims debited in error or the debits got "stuck" in a hold

status. This included researching original claim; researching debited

claim; confirming if there were payments and/or debits pending for the

provider; verified Electronic Funds Transmittal status had not changed;

investigated if National Provider Identifier number was correct and

populated; had any and all issues corrected as well as re-processed any

other claims that could hold up the release of debits in hold status.

o Assisted with the Check Transmittals and submission of live checks to

management for posting to the various Overpayments databases.

o Was responsible for various monthly refresh reports for the HMO

department utilizing JCL for the mainframe and ACL and Excel spreadsheets

for loading of reports and transferring of files.

o Received the Peer Recognition Award several quarters and was nominated

for the MVP award the first quarter of 2009.

Quality Assurance Technician / Business Systems Delivery Specialist,

Quality Engineering Systems Department, 2002-2003

o Conducted testing of the claims system utilizing manual and automated

scripts for maintenance and enhancements.

o Wrote Test Requirements and Test Cases based on the Technical Detailed

Design Documents provided by the technical staff and the Use Cases

provided by the business staff. From the Test Cases test scripts were

then developed and run, a process that was then being converted to

utilize Requisite Pro software.

o Projects were tracked utilizing Microsoft Project and defects from

scripts were recorded and tracked using Clear Quest.

o Acted as a liaison between the technical and business teams and performed

training on the HMO Claims Processing System when needed.

Business Information Systems User Specialist / Quality Lead / Analyst, Core

Claims Systems Support Department, 2001-2002

o Assisted Project Management staff with the preparation of test plans.

o Oversaw the execution of business user acceptance testing for claims

related projects and enhancements.

o Performed post-implementation analysis of claims systems issues to

determine business implications and recommend corrective actions to

management.

o Worked on the Automated Adjudication Project team, which was responsible

for saving the company $70 million and raised the automatic adjudication

rate to approximately 63%.

Kenda Systems, Inc., Wayne, PA

Information Systems Test Analyst, On assignment to IBC, Inc., 2000

o Tested enhancements and modifications to the claims Power MHS system for

the HMO product.

o Wrote and maintained scripts for the testing of modifications and

enhancements, reporting found issues, logged them into the Issues

Database and retested programming changes.

o Researched information on the AS400 system to be used in the testing

process and performed queries utilizing SQL.

Aetna US Health Care, Inc., Blue Bell, PA

Core Claims Systems Support Analyst, Claims Systems Support, 1998-2000

o Tested programming changes and updates to the claims system which

included Online, Batch and Pend processing functions.

o Supplied scripts for programmer testing and performed user acceptance

testing when programming changes were put into testing environments and

when moved into production.

o Participated in the switching from IDMS database to DB2 for Groups,

Closed claims and Member Identification number expansion.

Benefit Claims Specialist, COB Claims Department, 1997-1998

o Responsible for the adjudication of Point-of-Service claims involving

Coordination of Benefits.

o Audited the weekly COB Savings Report to determine both processor and

system accuracy when adjudicating claims involving coordination of

benefits. Researched each member with $25,000 or greater in paid claims.

Claims Supervisor, AT&T Claims/Customer Service Department, 1995-1996

o Supervised claims processing department managing ten Claims/Customer

Service Representatives.

o Reported inventory, status and compliance with contractual requirements

to upper management.

o Provided information for the development and enhancements of the claims

processing system created for this unique product and assisted with the

testing and demonstration of the package to upper management and the

client.

Claims Processor, Quality-Point-of-Service and COB Departments, 1994-1995

o Processed claims for the Point-of-Service product line. Determined if

managed care or indemnity benefits applied, contracted or non-

participating physicians were utilized and if the services received were

covered under the benefit plan chosen by the client.

o Conducted Pre-Existing Condition audits when applicable.

o Consistently exceeded all production and quality standards receiving

bonus incentives every month eligible.

o Chosen to respond to claim inquiries from both the Marketing department

and plan sponsors.

Contact this candidate