Team Lead

LYNNA N. WASHINGTON

Team Lead, Business Analytics Health Plan Operations

717-***-**** ******************@*****.***

EXPERIENCE SUMMARY

Dedicated professional with over 25 years of experience in healthcare and insurance who has the strong ability to prioritize and make well thought out decisions. Possess excellent research, written and analytical skills. Proven track record of leadership with extensive experience working with cross-functional teams across multiple product lines.

SKILLS & EXPERTISE

Medicaid, CHIP, Medicare, Market Place & Dual Eligible Demonstration

UAT Test Plans

SQL Management & Leadership support

Configuration Information Management

Pre-Check Run Oversight

SQL Claims Impact Reporting

Provider Specific Data in SAS format

QNXT Contract Configuration

ICD-10, CPT and HCPCS Level II

Cause-and-Effect relationship reporting

TOOLS & METHODOLOGIES

Tools: Microsoft Office 2013, Excel 2013, InfoPath Designer 2013, InfoPath Filler 2013, One Note 2013, Outlook, PowerPoint 2013, Publisher 2013, Send to OneNote 2013, Word 2013, Microsoft Silverlight, QNXT, WebStrat, Sales Force, Master Provider File,

Methodologies: Microsoft SQL Server 2008, Microsoft SQL 2014, Microsoft Visual Studio 2012, PDF Creator, QuickBase

Pink Book, UMCM, TMPPM, HHSC, and CMS

PROFESSIONAL EXPERIENCE

MOLINA HEALTHCARE – IRVING, TX

Team Lead of Business Analytics Health Plan Operations 2019 - Current

Oversee Claims and Configuration Business Analytics teams in order to comply with state and federal regulations including but not limited to implementing and executing initiatives to streamline and modify processes to ensure compliance. Directly overseeing a team of 10; and indirectly overseeing approx. 50.

Reviewed complex claims issues and provided comprehensive reviews and analysis including financial risk and assessment for Medicaid, CHIP, MMP, Medicare Advantage and Marketplace lines of business.

Worked as an interdepartmental liaison for Corporate Configuration to execute necessary benefit and contract compensation updates to QNXT in accordance with federal, State, and Provider contractual agreements.

Provided comprehensive root cause analysis of payment issues in regard to payment methodology configured in the system to determine and execute applicable updates needed to correct payment.

Responsible for state deliverables request such as required configuration updates, state required reporting, and implantation of new and updated initiatives.

Provided responses and reporting data for information requested by Office of the Attorney and Inspector General.

Worked with Encounters management to audit and provide guidance to source solutions for issues related to encounters submissions, acceptance, and rejections from HHSC.

Served as an Auditor for Adhoc audit request from senior leadership for areas of operational oversight including but not limited to Claims, Configuration, Contracts, and Encounters.

Responsible over seeing and auditing OIG and OAG inquiries

Responsible for auditing and signing off monthly Claims Summary Reports, and project monthly state reporting.

Back up for approving PTO request

Business Analyst (SR.) 2016 - 2019

Analyze existing claims processes and specific business rule logic to help neutralize potential financial losses

Provide analytical support for various business areas include appeals & complaints, pharmacy, member services, claims, provider services, and system configuration

Lead contributor for health plan User Acceptance Testing (UAT)

Guide continuous improvement of key organizational metrics associated with a wide range of Claims Adjustments and System Configuration

Inquiry Dispute/Appeals Resolution Coordinator 2014 – 2016

Efficiently researched and documented over 25+ Provider Dispute and/or Member Appeals daily

Key contributor for coordinating workflows between departments and formulating conclusions based sound on research

Responded and closed incoming Provider Disputes and/or Member Appeals accurately, timely and in accordance with all established regulatory guidelines

AETNA INC. - DALLAS, TX

Claims Benefit Specialist 2012 - 2014

Responsible for resubmission of Medicare and Medicaid claims, provider appeals, call tracking, NDC report and health plan resolutions

Processed claim forms, adjudicates for provision of deductibles, co-pays, co-insurance maximums and provider settlements.

Researched claim overpayments and requested funds.

DELTA DENTAL - HARRISBURG, PA

Claims Auditor 2010 - 2012

Responsible for:

Resubmission of dental claims, including coordination of benefits

One-on-one training to peers

Auditing claims

SYNERTECH – HARRISBURG, PA

Provider Specialist/Quality Control 2006 – 2010

Analyzed and validated new group contracts for process compliance to ensure billing information for group records is accurate and updating of billing information.

Handled escalated and provider appeals.

Obtained and updated billing renewal information in group records, performing changes to group record for billing related updates, communicating updates within the billing function and other internal functions

EDUCATION

Medical Assistant Academy of Medical Arts and Business Harrisburg, Pennsylvania

PROFESSIONAL AFFLIATIONS/ CERTIFICATES

Certified Medical Assistant (CMA) Harrisburg, Pennsylvania

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