Objective

Self-motivated and enthusiastic worker with vast experience in many different fields within Healthcare Compliance and Operations. Confident, hardworking, and committed to seeing results in whatever position I am in. Reliable and dedicated to finding a place that will benefit from my superior skill set and energetic drive.

Education

●Universidad Ana G. Mendez, Carolina, PR 2016 - 2020

Bachelor’s in social science Major in Psychology

●Universidad Ana G. Mendez, Carolina, PR 2021 - 2022

Master’s degree in Health Services Management

Professional Experience

Humana

Medical/Financial Risk Evaluation Analyst - Houston, TX (Remote) (2021-2023)

●Develops and analyzes business performance reports for claims data, provider data, utilization data and provides notations of performance deviations and anomalies.

●Identify, assess, and mitigate any medical or financial risk that arises from inadequate or failed processes, people, systems, or external events.

●Strong data analysis with identifying root cause.

●Creates and publishes periodic reports, as well as any necessary ad hoc reports.

Fraud Investigator - San Juan, PR (Remote) (2020-2021)

●Coordinate investigation with law enforcement authorities.

●Assembles evidence and documentation to support successful adjudication, where appropriate.

●Conduct on-site audits of provider records ensuring appropriateness of billing practices.

●Prepares complex investigative and audit reports.

●Understands own work area professional concepts/standards, regulations, strategies, and operating standards.

●Makes decisions regarding own work approach/priorities and follows direction.

Grievance & Appeals Analyst - San Juan, PR (Remote) (2018-2020)

●Managed client denials and concerns by conducting a comprehensive analytic review of clinical documentation to determine if a grievance, appeal, or further request is warranted to deliver a final determination.

●Respond to complaints, adhering to all regulatory, accreditation and internal processing timelines and guidelines.

●Collect, analyze, and interpret trend information to address and resolve non-routine business-related concerns.

Claims Auditor - San Juan, PR (2015-2018)

●Researching, documenting, evaluating, and settling claims typically focus on methods, tactics, and processes for completing projects.

●Rework and reprocess claims, process exceptions, work older claims, and handle other projects as assigned.

●Investigate the adjudication of claims for accuracy of provider contract payments in our payer systems, by ensuring correct claims payment.

●Responsible for supporting the policies and procedures ensuring compliance of timeframes for organization determinations.

●Identify and report inconsistencies or fraud relative to the adjudication of claims for contract compliance.

●Prepare and communicate issues and resolutions to high management and operational units.

MCS (Medical Card System) (2013 - 2015)

Team Lead (Call Center) - San Juan, PR

●Set clear team goals, coaching, handle escalated calls with strict adherence to confidentiality agreements, policies, and procedures.

●Processes medical service requests and telephone inquiries.

●Responds to irate callers in a professional manner. Provided support to other departments.

Skills

●Excellent written & verbal communication skills in English and Spanish.

●Proficiency with data analytics.

●Proficient in PC, knowledgeable in MS Office, FACETS, Excel, POWER BI, SQL, CRM, CGX, PAREO, MTV, MOAT, SCIOMINE, CAS, POWER MHS, CISPRO, CIS, DIG TOOLBAR, ARGUS, EHUB, FIT, CLAIM EXPLORER, PPIRATES, TRIAGE, INTAKES.

●Experience in Healthcare industry, data trends, claims processing, investigative process development, and auditing.

●Experience in Medicare and Medicaid regulations.

●Excellent time management and ability to work under minimum supervision.

●Experience in a corporate environment and understanding of business operations.

●Subject matter expert (SME).

References

●Available upon request.

Contact this candidate