NICOLA E. GRIFFITH-CARR, M.H.A.

TEL: 773-***-****

ady07j@r.postjobfree.com

OBJECTIVE: To acquire a position in an environment, that would allow me to utilize the skills that I have developed through my education, training and job- related work experience.

EDUCATION:

Master of Health Administration, Ohio University, March 2015

Bachelor of Arts, DePaul University, June 2006

EMPLOYMENT:

BLUE CROSS BLUE SHIELD

08/2018-Present

REGULATORY COMPLIANCE ADMINISTRATOR

Reviews and evaluates compliance issues within the organization. Collaborate with representatives from Legal, Internal Audit and leaders from business operational areas to conduct Compliance Assessments over business processes and operations. Responsible for the oversight and monitoring of compliance with federal and state laws and regulations that apply to business processes and operations. Develops, maintains, and revises policies and procedures for the general operation of the compliance program and its related activities to prevent illegal or improper conduct. Collaborate with the Enterprise Policy and Procedure team to identify, analyze and evaluate potential regulatory compliance risks. Independently research regulations and ensure Policies and Procedures are following rules and regulations of regulatory agencies. Responsible for keeping track of updated policies and procedures in the Access database. Respond to members allegations of discrimination in health care administration, ensured the concerns are documented in Access database, thoroughly investigated, and resolved in a timely manner. Utilizes the Sustaining Compliance process to assess control environments by testing the effectiveness of regulatory controls and working with the business areas to verify that test errors have been remediated.

EVOLENT HEALTH

09/2016-08/2018

CLAIMS AUDITOR & QUALITY ASSURANCE SPECIALIST

Ensured compliance with contract administration, demographic maintenance, and service level requirements.

Conducted claim audits which included auditing of senior level adjudicators. Audited Commercial and Medicaid claims. Supported business goals & system fixes by claim reviews, analyzing, identifying, and resolving issues

Documented and prioritized potential solutions to issues.

MANAGECARE STAFFERS/ PSYCHEALTH

10/2015-07/2016

BEHAVIORAL HEALTH CLAIMS COORDINATOR (Contractor)

Reviewed claims and ensured billing requirements were met.

Responsible for processing and handling Medicare/Medicaid and commercial claims.

Consistently apply Best Practice workflows for denials and appeals.

Confirm referrals and authorization.

ACCOUNTSTEMP

09/2015-12/2015

INSURANCE VERIFICATION SPECIALIST

Verified health insurance benefits and eligibility.

Followed up with Clients and Patients regarding financial obligations.

Executed customer service and project management skills.

MULTIPLAN

Rosemont, Illinois

10/2009 – 8/2015

QUALITY ASSURANCE ANALYST-CONTRACTS AND CLAIMS

Audited a sizable daily sample of physician and facility claims and rates sheets that were processed by internal and external users and systems. Worked with other analysts in the Quality Assurance team and provided valuable feedback to users in the operations, rates, demographic and contract areas. Confirmed claims and rates were processed correctly based on claims and contract data. Confirmed internal workflow was being followed. Compiled and delivered in a timely manner clear and concise summaries of all issues found in the audit, documenting in detail a summary of the issue and how the claim should have processed or how a rate sheet should have been linked. Determined critical errors or trends and escalated resolutions rapidly and accordingly.

MULTIPLAN

Rosemont, Illinois

03/2008- 10/26/2009

BILLING ISSUE RESOLUTION SPECIALIST

Effectively researched and resolved practitioner and hospital claim disputes. Determined root cause of claim payment discrepancies and facilitated, educated and updated claims in database as necessary to resolve issues. Reported system errors and incorrect contracts to Provider Demographics Maintenance and requested that they make changes. Educated clients on required adjustments on claims. Requested updated contracts from the contractors. Assisted Provider Account Representatives in correcting special handling cases. Efficiently interpreted the client’s EOB and ensure it matches the UB and the pricing in MPI systems.

VENTURI STAFFING/MULTIPLAN

Rosemont, Illinois

07/2007-03/2008

CLAIMS OPERATION SPECIALIST

Retrieved and reprised physician, surgery, hospital and drug claims. Processed electronic

and paper claims for various clients.

HEALTH NET PLUS/ FIRST HEALTH

Downers Grove, Illinois

10/2000-11/2005

TECHNICAL BILLING ANALYST

Repriced and audited Illinois and out-of-state Workers Compensation physician, hospital, surgery and drug claims in accordance with the State guidelines. Adjusted bills that often required an in-depth review and independent judgment. Researched and responded to client questions and complaints in regards to payments and pricing.

SKILLS:

Proficient in customer service, researching skills, policies and procedures, regulations, quality assurance,ICD-9/10 CPT and HCPCS, UB-92, interpretation of facility/physician contracts and EOBs, health claims examining, Microsoft Office Suite products which include Word, Excel, Access and PowerPoint

REFERENCES: Available upon request

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