Business Analyst Quality Assurance

LUCHANNA M. ESTOPIER

Sanford, NC. 910-***-**** ad5c0i@r.postjobfree.com linkedin.com/in/luchanna-estopier Fully Vaccinated

Business Analyst

An award-winning leader with 7+ years of experience championing the development and growth of long-term relationships with providers and healthcare systems through commitment, focus, and a tireless work ethic to produce remarkable results.

Team Leadership: Versatile leader with a reputation for successfully taking on additional responsibilities and balancing priorities to meet deadlines and continuously achieve established goals.

Relationship Management: Compassionate organization builder who values diversity and inclusion to cultivate and nurture relationships with internal staff, provider groups, physicians, practice managers, and clinical care teams to execute initiatives that benefit customers, providers, and health plans.

Operations Oversight: Forward-thinking strategist accustomed to quick promotions due to a proven record of managing provider networks, claims resolution processes, and quality service initiatives to support and increase financial and operational performance. Exercise outstanding business acumen to lead new plan implementations, navigate constant business changes, and continually work on being more effective.

Risk Governance: Subject matter expert of healthcare regulations, insurance policies, and state/federal healthcare programs, including Medicare and Medicaid, to elevate risk management and compliance capabilities.

CORE COMPETENCIES

Strategic Planning Provider Contracting Deal Negotiation Network Management Project Management Quality Assurance

Claims Investigation & Resolution Medical Billing & Coding Coaching & Training Cross-Team Collaboration

Proficient in healthcare systems, Department of Health and Human Services (DHHS) databases, Microsoft Office (Word, Excel, PowerPoint), and SharePoint.

PROFESSIONAL EXPERIENCE

Centene Corporation 2019–2023

Business Analyst/Quality Manager/Claims Liaison II, Charlotte, NC (2020–2023)

Tapped as Quality Manager/Claims Liaison at COO and Claims Manager’s request to strengthen provider relations and claims management processes, becoming the only staff member within the company to manage both functions. Direct five total staff and deploy issue resolution strategies for escalated/complex claims, payment disputes, and state/provider complaints. Review project plans submitted by multiple departments with a maximum $1M budget for approval. Audit completed claims to monitor trends and verify compliance. Govern new hire training and coaching activities.

Won Key Contributor Award in 2020 and 2021 for producing outstanding results across various departments.

Minimize provider turnover by generating monthly analysis reports and facilitating meetings to lead process improvement efforts that effectively tackle claims handling technical support, and customer service issues raised by staff and members.

Save the company 18% annually by ensuring timely investigation and resolution of claims escalations to avoid health plan penalties.

Revise existing policies after collaborating with leadership, finance, and configuration teams to uncover root causes of claims denials and payment integrity issues.

Meet/exceed productivity and quality assurance metric goals while managing staff virtually due to the ongoing pandemic. Increase productivity by motivating the team and leading efforts to automate existing processes.

Created and implemented centralized processes and reporting to track and enhance the visibility of state complaints/escalations, provider issues, team member productivity, and claims (volume, types, trends).

Centene Corporation (Continued)

Provider Engagement Specialist, Yuma, AZ (2019–2020)

Promoted to provider engagement role within a few months to serve as a liaison between 300+ providers and the organization. Drafted and negotiated contract terms and pricing. Coordinated credentialing and re-credentialing initiatives. Conducted orientation and training to educate providers on network access, new plans, revised manuals, and state policy updates. Performed audits to review, track, and evaluate contract compliance. Created, processed, and monitored vendor agreements and invoices.

Implementation Specialist, Charlotte, NC (2019)

Recruited to orchestrate claims management processes and implement a new health plan with a targeted 2021 rollout date.

Mayo Clinic, Jacksonville, FL 2016

Scheduler/Patient Service Specialist

Enhanced operational efficiency by directing all patient scheduling, check-in, and check-out processes, including greeting visitors upon arrival, understanding the nature of appointment requests, accurately responding to inquiries, educating patients on insurance coverage, and securing co-payments.

Received Customer Excellence Award for providing top-notch service for patients and providers.

AmeriHealth Caritas, Jacksonville, FL 2015–2019

Local Claims Research and Implementation Specialist (2016–2019)

Monitored and investigated subrogated claims, suspended claims, claims recoveries, and provider complaints in compliance with plan agreements, recovery guidelines, and operating procedures.

Member Services Specialist (2015–2016)

Established and maintained member/provider relations by delivering best-in-class service to effectively address issues and concerns regarding patient registration, insurance verification, benefits eligibility, appointment scheduling, account billing, payment processing, and claims handling.

Contributed to elevating quality care and patient outcomes by listening, understanding, and meeting patient needs.

One Call Care Management, Jacksonville, FL 2014–2015

Accounts Receivable Claims Specialist

Held full responsibility for overseeing multimillion-dollar accounts and verifying patients’ insurance benefits prior to handling their workers’ compensation claims. Reviewed aging reports to validate outstanding balances and initiated collection protocols to reduce delinquencies and minimize losses. Researched and resolved denials and underpayments with insurance carriers to obtain maximum reimbursement. Processed payments and performed account reconciliations and adjustments.

Emeritus Senior Living, Jacksonville, FL 2013–2014

Assistant Medical Records Director/Quality Assurance Manager

Supervised seven total staff and played a key role in directing day-to-day records management operations. Executed strategic plans to support company-wide initiatives regarding revising processes to collect, update, and maintain patient health information. Monitored and audited staff caregiving charts. Obtained authorizations from physicians, nurses, insurance carriers, Medicare, Medicaid, and Veteran Affairs (VA) to compile and release requested information in compliance with state and federal regulations. Assisted sales and marketing teams with community tours, sales admission processes, and new hire training.

PROFESSIONAL DEVELOPMENT

Certified Pharmacy Technician

Generate Results

Manage

Risks

Optimize Performance

Secure Providers

Identify Opportunities

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