Quality Auditor Customer Service

DONNELL MICHELL MURRAY, MBA, ALHC, CSA, ICA, ASQ-CQA

SUMMARY

Highly accomplished MBA professional with 20+ years of Managed Health Care experience in individual, group, commercial, self-funded, fully insured, Medicaid/Medicare/Medigap, FEHB and Affordable Care Act (ACA). Exceptionally organized and disciplined; ability to work with a cross functional team; ability to learn rapidly and meet tight deadlines. Generate and maintain audit reports and results confidentially. Familiar with CPT codes, ICD-10-CM codes and HCPCS, CHIP. Ability to make fact-based decisions and questioned those decisions not within the audit scope.

KEY SKILLS include: Managed Health Care, Marketplace Analyst, Quality Analyst Lead, QNXT Configuration Analyst, SME Claims, Quality/Contract Auditing, Claims Auditor, Provider Payer Experience, Resolution of Complex Claims Issues, Provider Credentialing, Recommend Process for Improvements, Familiar with Change Control Processes, User Acceptance Testing (UAT), Knowledge of Agile, Scrum, Jira, User stories, Customer Service, Call Center Auditor/Analyst, SQL, Microsoft Excel, Power Point, Word, Teams, SharePoint, Access, Data retrieval, updating various spreadsheets and databases

Profile: Team Leadership & Training, Policy & Procedure Administration, Provider Credentialing, Meeting time-service deadlines, Mentoring & Coaching, Summary Plan Benefit Auditing, Ability to Multi Task, QNXT Claims, Provider, Member Configuration, Project Management (IT Process Auditor and Subrogation Quality Auditor) Claims Subject Matter Expert, Quality Assurance, Self-starter and highly motivated.

Molina HealthCare/Contractor, Long Beach, CA September 13, 2021 – October 7, 2022

QNXT Configuration Analyst/User Acceptance Tester/Quality Analyst Lead

Deeper knowledge of QNXT Configuration

Selected by (ICS) employer to enroll in Health Edge University for Configuration classes to continue professional development

Experienced/trained in HealthRules Payor, HealthRules Design, HealthRules Manager

Thorough understanding and testing experience of Provider contracts and Member benefits

Performed QNXT Configuration for Claims, Provider, Member and Benefit Plans

Experience working in QNXT screens (configuration as well as regular screens)

Assigned to work the Marketplace project to perform UAT for new and renewal business

Document findings in the UAT and Assignment/Issues log as being completed or needed retesting

Perform provider configuration and claims affiliation with regard to resolving Edit 101 issues during User Acceptance Testing

Review Benefits in Benefit Plan Module to determine how to test specific benefits

Review Member’s Eligibility during UAT and swapped out members when necessary if Member was terminated

Utilize Crosswalk to determine the correct benefits payable per Benefit Plan

Provide timely updates on projects informing management of completion for review and review of the issue log

Wrote Processes and Procedures (documents) for MAPD, MPP, Marketplace for training Onshore and Offshore employees

Participate in daily and weekly meetings with cross functional teams and leadership

Worked on QNXT 5.9 upgrade and benefit configuration

Promoted to Quality Analyst Lead for AEE/TCS Integration project

Worked on MMP/MAPD Letter Implementation Project for 2023

SQL experience working in various Servers and Databases and testing scripts/queries

Jira experience in creating user stories, creating bugs and resolving defects and closing user stories

Wrote Test Cases to perform UAT testing and noted Pass/Fail status

Assigned defects to Developers for resolution and eventually moving the story to completion/UAT

Provided End to End testing and print and fulfillment for letter project

Tested in both Automatic Enrolment Engine (AEE) and TriZetto Communication System (TCS) for letter implementation project

Texas Children Health Plan/Contactor, Houston, TX March 5 - September 10, 2021

Operations Systems Analyst, I

Responsible for accurate and timely maintenance of provider information on all claims and provider databases.

Validate that provider information entered in databases adheres to business policies and state requirements.

Perform provider configuration and claims affiliation with regard to resolving Edit 101 issues to adjudicate claims.

Load new providers contracted to the network in QNXT and Cactus.

Execute changes in provider data and contracts as requested by Provider Network Management team.

Create contract records for out of network providers to properly adjudicate claims received.

Research and respond to inquiries related to provider data and affiliation status.

Load and maintains provider information in an accurate and timely manner to meet department’s standards of turnaround time and quality.

Monitor pended claims and work queues to update appropriate systems.

Identify claims impacted by configuration changes done in the system and sends reports to the claims administration department for reprocessing.

Maintains thorough and concise documentation for tracking of all provider, contract, benefit or Process Director changes related to Change Control Management or issues for quality audit purposes.

Kaiser Permanente/Contractor, Rockville, MD August – December, 2020

Configuration Analyst/Claims Adjudicator

Serve as assistant to the Supervisor supporting the Configuration team. *Responsibilities were revised due to the position going on hold until August 17, 2020. Team was preparing for Open Enrollment and my anticipated start date was to be April 2020 to learn the Configuration/Claims Adjudicator role. Assignments were project based and I completed all assignments as required. In doing so, it freed up the Supervisor to work on projects and to effectively manage the team during Open Enrollment.

Serve as the National Benefit Lead, responsible for logging in and assigning cases to the Plan Architect by the supervisor in EMWS

Identify issues with missing documents, i.e., Benefit Configuration Form, Rate Change Sheet prior to routing to the supervisor

Build/Modified Array codes used for plan configuration in KMATE, BETS

Update Benefit descriptions in KMATE

Add New Codes to the BAIS database for benefit configuration for 2021

Identify any issues regarding databases, EMWS, to supervisor for escalation

Participate in daily, weekly team meetings.

Familiar with Source of Truth (SOT) documents, Benefit Exception Forms

*Analyst will be responsible for analysis, system design and input of authorization, claims general and/plan benefit data elements in Xcelys, the host processing system, and other platform.

Ensures the provider, authorization and benefits configuration meets established business rules and procedures.

Modifies the provider contract, authorization rules and benefit plan configuration as required.

Research claims/bills for appropriate support documents and/or documentation.

Processes claims/bills as split claims when appropriate.

Forwards complete claims/bills requiring additional authorization to appropriate personnel for approval or denial.

Pends claims and receives pend claims for various types of research follow-up amongst other staff members.

Accredo/Express Scripts/Contractor, Indianapolis, IN Feb 3 – May 25, 2020

Eligibility/Billing Specialist, Sr.

Provide enhanced customer service and support for patient calls related to insurance/provider billing, copay assistance billing and patient invoices, focusing on one call resolution

Performs specialized account review and investigation, to respond to complex billing issues

Utilize a high level of independent judgment to establish and maintain effective relationships with patients

Rely on advanced knowledge of benefit verification, pharmacy, and medical billing practices

Recommend alternative funding programs, payment arrangements, other coverage options, and industry best practices to assist the patient with all situations related to their financial health

Leverage strong knowledge of billing practices, departmental system, and internal processes to decrease potential risk of bad debt.

Act as a liaison between both internal and external resources to reduce patient, physician, and client (payer) abrasion while facilitating a solution for the patient financial health, avoiding gaps in care.

Adjust patient’s account when deadlines were not made in submitting claims for payment

Anthem, Inc., - Indianapolis, IN April 15, 2019 – October 25, 2019

Performance Quality Analyst, II/Contractor

Responsible for driving service quality excellence by evaluating the quality of services and interactions provided by organizations within the enterprise

Demonstrate ability to audit multiple lines of business, multiple functions, and multiple systems using Salesforce, ISGB, WGS, ASCS, Medisys, Facets, BPM, NMF, NIPR

Use Access database in completing and documenting audit findings in conjunction with Salesforce

Participate in pre- and post-implementation audits of production team transactions within the Sales Compensation, Licensing and Credentialing (SCLC) team

Participate in weekly rebuttal call meetings by providing justification for either accepting or rejecting the error

Recommend process improvements and solutions which were implemented during my tenure

Act as a peer auditor by providing training to new Quality Analyst/temp contractors

Created a Performance Quality Auditor Manual for new Quality Analysts to be used in performing audits for the SCLC production team

Perform telephone audits using the Verint Impact 360 system in determining if associates were following the SOPs for hotline calls/first call resolution, emails, faxes, member or agent correspondence

Completed courses in Agile, Jira, User Stories and Features, Scrum Master in preparation for Operational Readiness

Participate in Program Increments PI6 & PI7 sessions for BITS and COINS migration

Healthscope Benefits/Contractor - Indianapolis, IN October 1, 2018 - April 12, 2019

Quality Attestation Specialist/User Acceptance Testing

Test new groups plan benefits prior to and during implementation for accuracy in Health Axis system

Test plan changes for all groups and renewals/User acceptance testing

Participates in implementation calls with client, account manager and benefit programming departments

Worked on claims data and extracted data from various sources such as Healthaxis

database and Mainframes.

Update accumulator loads, making sure benefits are calculated according to plan benefits

Review Implementation Questionnaire/Processing Guidelines against the Benefit Matrix for correctness in applying claims benefits

Provide status testing updates for groups being tested

Document findings and make recommendations to correct testing insufficiencies in Benefit Programming Issue log

Actively contribute to team with suggestions on how we could improve/streamline our processes and served as a mentor to team member(s)

Provide timely updates on projects informing management of completion for audit or review of issue log

Chickasaw Nation Industries/Contractor - Rockville, MD January - April 2018 Medicaid Claims Quality Auditor/Managed Health Care

Verify accuracy of CHIP, Medicaid claim being complete, recipient information (eligibility), Third Party Liability and related PHI

Review Provider information, was provider registered, licensed and eligible to provide/refer/bill for services under review?

Review for correct filing, filing timelines, prior authorization, proper fee schedule, duplicate payment history, adjustments to claim within 60 days of payment

Review claim passes logical tests/check for logic edit errors, for example, (incompatibility between gender/procedure, rental payments after equipment was purchased, claims paid after policy lapsed)

Knowledge and experience with the provider enrollment, provider credentialing processes and systems (PECOS, NPPES, state licensing databases)

Document findings in the State Medicaid Error Rate Finding (SMERF) system.

Record final determination, if correct note in SMERF, if errors, identify correct error code based on codes in the PERM manual, select qualifier, identify over/under payments, include an explanation, identify relevant policy citation, capture screen prints for second level review

Worked with several different processing systems, Facets, QNXT, HPE and MMIS- Medicaid Management Information System

Secured sensitive data in compliance with HIPPA regulations

Aultcare Health Care - Canton, OH June - September 2018 (full-time)

Claims Internal Quality Auditor/Managed Health Care/Contractor October 1 - November 30, 2018 (part-time)

Worked as part of a team to maintain and decrease commercial claims’ inventory prior to transitioning to QNXT Audit UB and 1500 claims verifying benefits were paid correctly and in accordance with appropriate plans and policies

Review ONBASE (claims imaging screen), CCA (utilization system), databases, training manuals and fee schedules for appropriateness of claims handling

Resolved issues with member attributes, enabling multiple rules associated with

member lookup process in Facets

Involved in transformation and research of Facets for initial process to end.

Evaluate all evidence with the goal of creating positive outcomes for client's claims

Review and interpret employer plans of health coverage and secondary insurance policies to individual claims

Suggest areas for improvement and efficiency

Maintain the highest level of privacy

Caring Associates Counseling Group, Inc. - Brownsburg, IN August 2017 - December 2020

General Manager - Interim/part-time (Volunteer worker) November 2019 – August, 2020

Mange office for the CEO/Owner of outpatient counseling group

Remain HIPAA Compliant while accessing Private Health Information.

Secure sensitive data in compliance with HIPAA regulations

Safeguard medical records, computer systems and verify signoff for release of PHI

Onboarding, training and supervising student externs from Ivy Tech, WGU

Corroborate with management and team members regarding ramp up and ramp down in staff

Made business decisions in alignment with business goals of the organization.

Create/manage Access data base for marketing schools in 10 localities for growing the clientele

Schedule intake assessment for Psychologists, Social Workers, and clinicians for the Group practice.

Bill and handled billing discrepancies for multiple insurance carriers and balance bill the client

Complete provider credentialing process for insurance carriers

Establish time frames for completion of deliverables – meeting deadlines

Perform other functions as required by the CEO.

Golden Rule Insurance Co/UnitedHealth Care, Indianapolis, IN

Senior Claims Adjuster, Feb - Aug 2017

Strong written and oral communication skills

Adjudicated Individual health, Medigap, Medicare, Medicaid claims

Trained adjusters on claims issues and participated in ongoing training

Addressed members’ concerns by oral and/or written correspondence

Resolved Department of Insurance complaints/grievances

Suggested new ideas for implementation to improve claims processes

Performed lead adjuster responsibilities answering adjusters’ questions

Verified accuracy of claim payment or denials prior to release of claim

Investigated injury, auto claims, 3rd party liability claims/Subrogation

Exceeded production goals while maintaining quality

Refer large dollar claims and trigger diagnosis to case management department

Refer claims for possible waste, fraud and abuse to Special Investigation department

Took the initiative to learn about Facets since the organization was converting to Facets in the future

Senior Claims Quality Auditor/Analyst, - Indianapolis, IN Dec 2002 - Feb 2017

Subject Matter Expert - Claims Interest/Penalty Reduction Project

Review Quality Control Pends/claims for auditing in accordance with plan benefits.

Audit Floor, Case Management, Worker’s Compensation and Medical History Review files

Suggest areas for training or improvement/corrective action plan

Contribute innovative ideas to the success of the department.

Review state variations for compliance with policy/plan provisions

Workflow management

Responded to Department of Insurance complaints/grievances

Analyze overpayment and underpayments in files for subrogation recoveries

Revised/edited policies and procedures guidelines for the audit manual

Served as the SME for reducing claims interest/penalties and reduced the number of days for processing case management files from 9 days less than 2 days

Subrogation/IT Process Auditor Projects, Indianapolis, IN 2014 – 2015

Serve as the lead auditor and successfully created a Subrogation Audit Program to audit Subrogation Specialists’ files for implementing the paperless agenda in 2015

Served as the co-auditor on an IT Process Audit

Interviewed Subject Matter Expert and Manager to gather criteria to establish audit plan

Collaborated with management from various business areas for approval of the audit plan

Created Excel workbook to report individual results.

Presented statistical results using Pareto and pie charts

Identified gaps, trends, and analysis for continuous improvement

Delivered results to management in a close out meeting during a PowerPoint presentation

Praised by management from various business areas for doing a great job

Visio, Share Point and Access experience

EDUCATION

Master Business Administration (MBA), Human Resources – (3.91 GPA)

Indiana Wesleyan University, Marion IN

Bachelor of Science,

Elementary Education Major

Computer Science Minor

Indiana State University, Terre Haute, IN

CERTIFICATIONS

Certified Associate Project Management (CAPM) – (completed coursework – 2016)

American Society Quality - Certified Quality Auditor /ASQ-CQA 2012- 2020

PROFESSIONAL ASSOCIATIONS

American Society Quality - Certified Quality Auditor /ASQ-CQA

International Claims Associate (ICA)

Health Insurance Associate (HIA)

Associate, Life Health Claims (ALHC)

Customer Service Associate (CSA)

https://www.linkedin.com/in/donnell-michell-murray-58ab3428

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