Manager Management
Resume:
RODNEY B. DAVIS
PHOENIX, AZ.
*********@*****.***
PROFESSIONAL SUMMARY:
Dedicated individual with over 30 years experience in healthcare and finance management in addition to extensive experience with compliance and regulatory standards.
EDUCATION:
Bachelor of Science, Business Administration & Management
Rust College Holly Springs, MS.
TECHNICAL SKILLS:
Microsoft Office, Oracle, SAP Lotus, AS400, (CATS) PMMIS, ACT, DIAMOND, KRONOS, AFIS, ETS, Med Hoc, FileNet, Peoplesafe, MC400, QNXT, FACETS, MDE, EDM
INDUSTRY KNOWLEDGE:
Knowledgeable of HIPPA, Medicaid (AHCCCS), Medicare Part A, B, C, D., HCFA, UB92, CPT, ICD-9 codes, CMS and Workman's Compensation and Credit reporting
CAREER HISTORY:
Trizetto Corporation Team Lead Encounters 2015
Assisting with the process of claim adjudication, ensuring that eligibility (including COB), referral/authorizations, and payments are appropriate based on contracts, regulations, industry claim payment standards, and company policies and procedures and assisting members and providers in the meeting of commercial and/or governmental medical claim and dental reimbursement, representing the company throughout the transaction.
Examining and entering complex claims for appropriateness of care and completeness of information in accordance with accepted coverage guidelines, ensuring all mandated government and state regulations are consistently met.
Processing claims for multiple plans with automated and manual differences in benefits, as well as utilizing the system and written documentation to determine the appropriate payment for a specific benefit.
Maintaining external and internal customer relations by interacting with staff regarding claims issues and providing service as the key contact for clients and working as directed with the client’s vendors.
Researching and ensuring accurate and complete claim information, contacting insured or other involved parties for additional or missing information and updating information to claim file with regard to claims status, questions or claim payments.
Identifying and referring all claims with potential third party liability, such as subrogation, COB, MVA, stop loss claims and potential stop loss files and approving, pending, or denying payment according to the accepted coverage guidelines.
Assisting in training of new groups and new staff as needed; assisting the management team in problem resolution, planning and overseeing workflows; testing and preparing documentation and updating current documentation; as well as providing suggestions and recommendations to improve workflows and departmental efficiencies.
CMDP AZ.Dept.of Child Safety (Corporate Job Bank) 2015 -2015
Encounters Specialist
Oversee the business aspect of Eligibility, Enrollment, and Encounter/Claims submission and supervised processing for the foster care population.
Worked in collaboration with the IT Department to ensure the efficient and logical processing of encounters/claims, and assisted in resolving any technical issues that may arise
Provided advising and assistance in the planning and development of system and program enhancements or changes.
Managed the analysis and review of encounter/claims and enrollment processing and directing improvements through operational enhancements and policy changes
Responsible for developing, establishing, enforcing and clarifying policies and procedures for eligibility, enrollment, and encounters/claims operations according to all applicable rules and regulation while interfacing with AHCCCS to develop, maintain and update policies, service definitions and codes, and rates information related to Title XIX and information among the health plan.
Conifer Health Solutions 2014- 2015
Recovery Analyst/QA Audit Specialist, Appeals and Grievances
Supported the Claims Department by clearing pended encounters from the AHCCCS Pend Report
Compiled reports on outstanding encounters subject to sanctions and processing adjustments as needed
Responsible for pending encounters from the monthly AHCCCS report including analysis, issue reports monitoring and outstanding resolution necessities
Assisted with claims adjustments related to aging encounter pends
Researched aging encounters (over 120 days) quarterly for possible sanction.
Worked in collaboration with Reinsurance Specialist and Recovery Team
Completed acknowledgement, resolution and/or extension letters for member and provider appeals and grievances in accordance with CMS or timeliness regulations
Appropriately applied CMS rules/regulations, ICD-9, CPT/HCPCS coding and all other applicable regulatory or statutory regulations to resolve member and provider appeals and grievances
Independently researched, investigated, resolved and documented member and provider appeals and grievances in accordance with, CMS regulations
Received and created member and provider appeal and grievance case files including completing and mailing acknowledgment letters within mandated timeframes
Tracked and trended claims or provider issues identified during the appeal process and oversaw the investigation and resolution of the trend including root cause analysis to ensure timely resolution.
CVS/Caremark (Medix) 2013
Medicare Grievance Analyst
Reviewed, analyzed and processed grievances with external accreditation and regulatory requirements
Maintained internal policies and events
Achieved excellent written and verbal communication skills
United Health Care 2007 - 2013
Senior Appeals Analyst/Claims Business Process Analyst
Reviews and researches correspondence and complaints related to Medicaid appeals and grievances to determine appropriate actions and
Ensure policies and procedures are properly met and contacts members and providers by correspondence to obtain needed information.
Adjudicated encountered claims in compliance with HIPAA guidelines
Performed root cause analysis of claim errors (system edits/pends/billing errors/processing errors)
Identified opportunities to improve and increase adjudication and encounter acceptance rates.
Contract Work 2006 - 2007
(State of AZ, ADOA, ASML Lithography, Honeywell
Account Analyst /Collection Analyst
Managed accounts payables commercial account receivables for assigned client base of internal vendors and employees
Oversaw all departmental invoicing
Purchase order tracking
Accountable for daily and monthly correction reports.
First Health Priority Services 2005 - 2006
Operations Supervisor
Subject matter expert interfacing with customers and insurance companies on Workmen's Comp claims
Managed day to day operations in hiring, training, payroll, performance evaluations and corrective action.
Prudential Financial 2004 - 2005 Cost Management Analyst
Managed account tracking, auditing and reporting transferee expenses along with tax policy and reimbursement
Compiled data for annual and midyear checks for employees and vendors
Analyzed costs utilization data to provide financial reports to Management
Jaburg & Wilk PC Accounts Receivable Manager 2004
IKON SR Collections Account Manager 2002 - 2004
Cummins Southwest Credit/Collections Manager 2000 - 2001
Micro Age CC Senior Credit Analyst 1997 – 2000
Olsten Health Svcs. Senior Medicaid Coordinator 1993 – 1997
Maricopa Cty Dept. Health Svcs. Business Office Analyst 1990 – 1993
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