Lorraine D. Tapia

813-***-**** ad2zxr@r.postjobfree.com

Accomplished and innovative health plan strategist with an outstanding background in performing data collection and oversight of all workflow controls for claims management with over 16 years of experience. Managed strong claims resolution based around Federal and State regulations. Strengthening relationships with internal and external client for continued revenue and growth. Drive transformation change through data analysis, process re-engineering, and streamlining workflow and controls. I am in search of, a career path opportunity where I can utilize my skills, dedication, efficiency, and job ethics toward promoting and helping future growth. AREAS OF STRENGTH

Strong Research Skills Analytical Skills Strong Contract Knowledge Strong Xcelys Skills Strong Attention to Detail Claims Resolutions Contribution Claims Path Highly Organized Proficient In Microsoft Office Excellent Written Communication Superb Verbal Communication Ability To Multitask EXPERIENCE

August 2016-Present

Provider Data Management Analyst II Centene Corporation Tampa, FL Perform provider data management related activities based on plan and contract specifications and standard business rules – includes data analysis and entry, review of data via internet sites and other systems, usage of multiple systems and applications to validate data is complete and accurate, and investigation and resolution of data issues.

• Set up and perform facility (hospitals and clinics) enrollment in the provider data management system.

• Enroll providers and practitioners in the provider data management system.

• Update facilities, providers, and practitioners with claims payment information

• Research, review and make updates within the provider data management system per provider requests.

• Research correspondence and communication for credentials function

• Perform quality service checks on systemic data, inclusive of claims processing and provider directory information.

• Perform research and resolve problems as necessary. Claims Analyst Centene Corporation Tampa, FL

Research complex claim issues relating to claims payment disputes and work with internal departments and markets for resolution; Research provider internal documentation for final determination in relation to claim disposition. Perform prepayment and post payment claims review and processing; root-cause analysis for identification of payment and/or denial issues.

• Knowledge of Correspondence, Appeals, Authorization, Request Management System (RMS) Tickets, Itemized Bills and Special Projects and Meridian Claims Systems (MCS).

• Responsible for High Dollar Claims. Physician / Hospital Medicare including research information on claims, research contracts, compliance guidelines, eligibility, and authorizations. Responsible for confirming correct pricing from Optum in web-Strat depending on price methodology and provider’s contract. Research for duplicate claims in our system to reduce any duplicate payments to providers. Special pricing, refunds, and adjustments on resubmitted claims.

• Research members plan in Medicare Benefit Master Library system to verify correct copayment if required for service.

June 2015-June 2016

Business Auditor Prestige Health Choice Tampa, FL

• Identifying strategies and problem analysis for resolution of provider issues and escalations; Collaborate with Account Managers/Account Executive for problem solving; Run reports and maintain provider data; Participate in First Alert and Client Configuration Review calls for claims adjustments and final resolution; Knowledge of JIVA and Diagnosis Related Group.

October 2008-June 2015

Claims Benefit Specialist Aetna Health Insurance Tampa, FL

• Processing Stateside, Medicaid and Medicare hospital claims; Review for coverage eligibility and identify discrepancies and collaborate with customers for resolution; Review plan guidelines against medical records to determine eligibility for benefits; managed a case load of 80 to 110 claims.

• Placed outbound calls to members/providers to increase satisfaction, retention, and growth by efficiently delivering competitive service to members, providers, and hospitals. September 2002-September 2008

Sales Executive/Operations Manager TB Appraisal Tampa, FL

• Managing screening interviewing candidates for appraiser positions. Source and screen candidates that best fit the company’s future goals. Duties include establishing hiring criteria, understanding recruiting needs and finding the right candidates.

• Developing new client base and client retention; Provide administrative services; Identify qualifying applications, conduct interviews, prepare payroll; Review and approve supply requisitions; Liaison between clients and home appraisal corporations.

ACCOMPLISHMENTS

2012 – Awarded Certificate for outstanding Achievement and Contribution to Joint claim Administration 2011 – Nominated for Aetna Silver Excellent Award for Collaboration/teamwork 2010 - Lead on proactive calls coordinator support for Joint Claims Administration 2002-2008 Tampa Bay Appraisal - Extensive experience managing a variety of different clientele through various levels of communications from independent Agents, Banks, Realtors, and Brokers. Instrumental in expanding the company’s service area from five counties to national. LEADERSHIP

Lead on proactive calls coordinator support for Joint Claim Administration REFERENCES

Available upon request.