Customer Service Project Manager

RoSalyn Santiago

Mobile: 614-***-**** : Corona, CA 92879 E-mail: *******.*.********@*****.***

Professional Competencies

Astute, results-oriented, Bachelor-degreed professional seeks suitable, upwardly mobile position that welcomes a seasoned professional with an exceptional ability to work under pressure. Professional career reflects over 14 years of healthcare experience with proficiency in claims, enrollment, internal auditing, over-payment recovery and data analysis. An out-of-the-box thinker with a flair for identifying and adapting emerging trends to analyze and streamline processes. Ability to quickly grasp procedures and methods, easily adapts to new situations, communicates in a clear, concise, and understandable manner and coordinates with all levels of personnel.

Knowledge, Skills and Abilities:

Commensurate professional in analyzing, examining, investigating, adjudicating and authorizing claims for all aspects of insurance entitlements

Outstanding oral and written communication skills

Thorough knowledge of QNXT, FACETS, Xcelys, MHC and Diamond claims processing systems

Thrives in time-fused and deadline-driven environments

Conducted quality audits for claims associates

Extensive knowledge of Encoder Pro, Med-Assets, Medicaid, Medicare & Commercial health insurance policies & programs

Working knowledge of conducting data analysis for reporting via SQL server and Microsoft Access databases

Proficient in the complete Microsoft suite with knowledge of developing/building web pages

Ensured assigned projects meet or exceed quality standards

Career Achievements

Certified Associate Project Management (CAPM) training in progress Professional Medical Coding course

Completing Certified SQL User Training Webmaster/Web Designer

Completed CompTIA A+ PC Technician Certification Basic Spanish

Professional Background

Healthcare Scouts Insurance Plan Specialist/Data Analyst 04/2015 to present

Performs high-level contract overview to ensure accuracy of contract terms and conditions. Ability to analyze, trend and escalate issues as needed to the appropriate stakeholders

Review and research payment account adjudication, billing results and disputed claim patterns for assigned payers

Works required reports (daily, weekly, monthly) to ensure claims processing integrity based on established guidelines provided by management

Coordinate efforts with stakeholders to drive changes in auto adjudication, aging and cycle time

Leads and participates in meetings as needed. Provides feedback to operations and other stakeholders regarding payer trend status resolution.

Talent Strategies Claims Quality Analyst/Project Coordinator 11/2014 - 02/2015

Ensured the correct configuration and functioning of the Qnxt claims processing system

Created project work plans for provider resolution claims project

Provided in-depth root cause analysis along with proposal and recommendations for next project phase

Audited claims by reviewing all system data as well as payment methodologies to ensure compliance with all contractual obligations as agreed to by the group, subscriber and provider

Attended work group meetings and assisted project manager with determination of project scope and requirements

Effectively and accurately communicated relevant project information to work group, project team and other key stakeholders

Kept Project Manager(s) and workgroup informed about project status and issues that may impact project deadlines

Perform technical and analytical work to support the functional and reporting requirements of the Business Process Improvement (BPI) unit

Consult and collaborate with Claims, configuration, and IT departments to ensure that all issues identified by claims department that contributing to inaccurate or inefficient processing are addressed quickly and effectively

Maintain an up-to date knowledge of national and state-wide code sets, standards and regulations pertaining to the handling of claims documents

UnitedHealth Group Senior Recovery Resolutions Analyst 09/2014-10/2014

Provide claims expertise support by reviewing, researching, investigating, negotiating, and resolving various claim types as well as recovery and resolution for health plans, commercial customers, and government entities

Analyze, identify trends, and provide reports as necessary

Ensure adherence to state and federal compliance policies, reimbursement policies, and contract compliance

Manage subrogation files

Cigna Healthspring Senior Claims Analyst 4/2012-09/2014

Evaluate claim submission for completeness, program eligibility status and medical appropriateness

Initiates correspondence requesting information on incomplete forms in order to adequately process claims

Enter primary care encounter information and for fee for service claims received both in paper and electronic formats

Identify, track and reconcile overpayments made to providers ensuring that overpayment recovery is made and reported

Researche and identify potential overpayments made to providers through independent work

Utilize provider contracts system to manually price claims according to contract terms

Prepare and send correspondence to providers notifying them of claims overpayments

Perform QA system, unit, acceptance, regression, load and functional/performance testing in QNXT using automated and manual testing methods

Insurance Overload Staffing Claims Analyst 7/2010 – 11/2011

Examine claims to identify key elements and processing requirements based on diagnosis, provider, medical policy, contracts, policies and procedures

Efficiently and accurately processe product- or system-specific claims to ensure timely payments are generated

Calculate deductibles and maximums, as well as research and resolve system pends

Process high and low dollar volume claims in accordance with standard policies and procedures

Assist Customer Service Reps by providing feedback, resolving issues and answering basic processing questions

Perform QA system, unit, acceptance, regression, load and functional/performance testing on Facets

American Red Cross Administrative Grant Assistant 3/2010-7/2010

Ensure compliance with applicable federal and/or state laws, regulations, and/or policies and procedures

Ensure all required aspects of the grant review are completed according to specifications and to contract requirements

Meet and confer with management to resolve problems and coordinate services

Research and use agency and community resources and services

Update and maintain online grant monthly reporting /tracking system

Complete assigned projects in a timely fashion amine claims to identify key elements and processing requirements based on diagnosis, provider, medical policy, contracts, policies and procedures

Manpower Temporaries Member/Claims Services Representative 11/2008-10/2009

Provide first-call resolution for providers by investigating or reprocessing claims based on provider’s issues

Answer and document all incoming calls for the Member Services Department

Research and respond to inquiries of existing members, prospective members, group representatives, outside service providers and others regarding health plan benefit, claims, services and products

Respond to complaints from members concerning Health Plan benefits, account status, provider and/or member claims status, payment history and medical services

Performed other duties as directed

Sentara Healthcare Administrative Assistant/Claims Clerk 10/2001-9/2007

Enter claims information for equipment received both in paper and automated format

Research and respond to inquiries regarding, claims, services and products

Process receipts for stock and non-stock supplies and equipment; put away stock; pull, pack and stage outbound stock for delivery or pick up

Receive and arrange shipment of merchandise to vendors for returns or repairs

Communicate daily with various departments within the hospital system to locate purchased supplies and equipment ensuring timely payment to outside vendors

Contact vendors to verify proof of delivery for hospital supplies, equipment or services

Respond to customer service inquiries and provide excellent customer service to hospital personnel seeking information, equipment and/or supplies

Education

Certified Associate Project Management Career Academy (In progress) Needham, MA (online)

CompTIA A+ PC Technician Certification The Community College of Baltimore County December 2013 Catonsville, MD

Bachelor of Science Norfolk State University Norfolk, VA

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