Senior Claims, Benefits and Billing Coordinator

WILSON DE LA VEGA

** ******** ***, *******, ** **810 * 786-***-**** * *****@*****.***

Highly qualified and accomplished financial professional offering several years of experience in leadership and direction in the health insurance and services and financial products industries. Combined expert technical, analytical qualifications along with broad knowledge and background in healthcare claims, risk management, and due diligence. Offer strong background with Hospital and medical claims and billing. Contributed to the business profitability, viability and providing great service, asset management and negotiating strategies. Excel in professional staff training, development, mentoring and leadership.

Core Business Competencies

Claims/billing Analysis Quality Control Workman’s Compensation

Financial Reporting Strategic Planning Contract Negotiation

Process Improvement Configuration of Benefits Training/Development

Team Leadership/Motivation Liaison between providers/ health plan Eligibility/ Auditing/Compliance

and Corporate

Career Highlights

Leveraged strong negotiation skills, achieving ranking as a top producer surpassing company’s quotas

and consistently creating favorable outcomes. Negotiates assigned contracts and letters of agreements with physician groups and ancillary providers that result in high quality, cost effective and marketable providers. Maintains tracking system and publish reports according to departmental procedures.

Delivered dynamic, highly effective presentations that were clear and concise conveying facts and information in an engaging manner. Devised winning claims negotiations, and trained/managed the team that ranked #1 in company processing claims for 5 years.

Utilized critical thinking and creative problem-solving abilities to resolve complex financial challenges while handling a voluminous number of files, and received multiple Customer Service Awards and personalized thank you letters.

Spurred business growth and long-term profitability through effective use of client relationship management techniques while closing more contracts and outperforming the competition.

Experiences & Achievements

ROBERT HALF/Hudson River Health Care, 5/2015-Present

SENIOR BILLING COORDINATOR-EI/CPSE

Review of current EI/CPSE documentation and Provide analysis of current workflow and assessment of automated options. Provide options for transforming into the better solution. Also Provide recommendations of changes needed to the current EI/CPSE (Early Intervention and Committee on Preschool Special Education) proposed workflow solution to best support the Client’s and provider’s needs.

Provide support as directed by the EI/CPSE and Service Coordinators for Business and Technical Teams.

Demonstrated success in past roles where Workflow Management, Business Workflow Analysis, and Business Process Reengineering skills were utilized to ensure system functionality, security, reliability, and performance were delivered in-line with client expectations and quality control.

Experience with industry-standard workflow and business process tools (NYEIS/HCS System, EI Billing NYEI Fiscal Portal

IBM and Cognos Report System as well as internal ECW. (EClinicalWorks System).

Provided options for transforming into the better solution for billing procedures for providers such as PHD,CSW,OT, PT, ST

Special Education Teachers and OnGoing Service Coordinators.

CENTENE/Sunshine Health HMO Medicaid/Medicare, 6/2013-4/2015

PROVIDER SERVICE / RELATIONS REPRESENTATIVE II

Successful in resolving provider inquiries via telephone and written correspondence in a timely and appropriate manner. Provide consultative support to internal & external clients by researching & assisting with resolution of benefit design, claims issues, authorizations for HMO, LTC, Welfare Child, Healthy Kids, Medical Management.

Affirm quarterly Provider Forums to service and educate clinicians on new products or product enhancements for HMO Medicaid through effective calendaring and time management skills.

Document all activities for reporting and resolution through the customer relationship management application (CRM). Follow-up and ensure closure with the contact who initiated the inquiry. Working in connection with Care Managers, Provider Relations Specialist, LTC as well as Provider's contracting and credentialing process. Assisting in HEDIS medical record retrieval and other projects as needed. All outreach documented in compliance with department standards. Also Work in partnership with Credentialing Department on activities relating to clinicians such as the submission of completed applications, site visits, contracts and materials related to credentialing necessary to comply with plan standards. All contact documented on CRM for better quality and exceptional service. Worked with FileNet imaging, AWD workflow, Amisys and CRM.

Technisource Healthcare, 2011-2013

SENIOR BENEFITS CONFIGURATION ANALYST/COORDINATOR

Responsible for different benefit plans and products configuration offered to the clients by GHI & HIP. Accomplished, organized and configured the structure of benefits in to the claims administration system. Evaluated and approved complex client benefits.

Successfully creating benefit plans, loading contract data and updating Medicare/Medicaid fee schedules

Configured benefits responsibilities that includes benefit and claim testing. Load health plan benefits into

claims system each new calendar year as well as new health plans contracts and program changes.

Analyzed and interpreted various health plan contracts, configured and pass through contracts as applicable based on the health plan.

JIB of the Electrical Industry, 1996 – 2010

HEALTHCARE CLAIMS/BENEFIT SPECIALIST

Attained higher union grade and promoted to senior claims examiner within 12 months to process and adjudicate claims for local union 3 and local union 501 for a total of more than 10,000 members and dependents

Analyzed Hospital and Medical claims/bills to determine eligibility and method of payments according to member benefits. Acknowledge as a valued employee based on outstanding leadership and professional business acumen, paving the way to achieve corporate awards for exceptional monthly production.

Consistently met and surpassed all established quotas throughout tenure by leveraging impeccable organizational skills to effectively manage more than 50 files daily for 2 different accounts. Handle and evaluate diverse medical claims working in sync with Utilization Review department to process payments for delicate surgical bills/claims, diagnostics and PT treatments.

Achieved outstanding results in saving the company hundreds of thousands of dollars through negotiations for surgical bills, hospital bills, as well as litigations and lawsuits to members.

Education, Training and more core skills upon request

MCSE Certified in Information Technology and Networking Specialist 2002

COMPUTER CAREER CENTER, Forest Hills, NY

Associate Degree, Business Management/Administration 1995

LA GUARDIA COLLEGE, LIC, NY

Certified in Medical Terminology and billing coding

BLUE CROSS BLUE SHIELD

SYSTEM USED AT CENTENE CORP.

Citrix - CRM - Amisys - AWD- IBM-FileNet - Cnet (Intranet)

Portico-PDM (Provider Data Management) Contracting and Credentialing.

TrueCare (Authorization-Utilization Review)

Excel 2010-

(NYEIS/HCS System, EI Billing NYEI Fiscal Portal

IBM and Cognos Report System as well as internal ECW. (EClinicalWorks System).

IMAX (Imaging) Emdeon,PaySpan,Cenpatico

EDI-Medicaid – DCF (Dept Child & family)

MCNA (Dental), DHW,

HM S-Health Maintenance System UNIVITA- DME

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