ADDRESS: CONTACT:

P.O. Box ***** 901-***-****

Memphis, TN 38181 adye3w@r.postjobfree.com

Creative Leader, Analytic, and experienced senior level business analyst with expertise in business and financial analysis. Results driven project manager with strong communication skills. Proven ability to develop procedures to streamline and improve daily operations of business.

EDUCATION:

May 2024 Walden University, online

Degree: Bachelor of Arts in Business Administration May 1998 Greenville High School, Greenville, MS

Degree: High School Diploma

PROFESSIONAL EXPERIENCE:

Jan.2020- Present Cigna-CareAllies, Remote

Senior Analyst/Process Improvement Coach

Manage strategic operations and support to Independent Physician Associations (IPA), including contracting, data integrity communications and relationship management, utilizing the Value-Based Care model;

Manage key performance measures with revenue, expenses, medical loss ratio (MLR), proper chart documentation and completion of HMRs;

Develop and present presentations for providers, provider staff, and physician leadership during monthly operational meetings;

Track and report key program performance metrics, including utilization, HEDIS, STARs/quality performance, HCCs, P4Q and CPT II codes; knowledge of coding and medical terminology

Execute the root cause analysis and resolution to improve low performance;

Design plans for enhanced provider engagement in quality initiatives;

Partner with other internal departments, including but not limited to Health Services,Finance, Claims, and Coding in order to develop solutions for strategic business needs Dec. 2014- Jan. 2020 Wellcare Healthcare, Inc., remote Operations Account Representative

Educated providers on common billing practice errors and reimbursement policies.

Specialized in Resolving DOI and Provider Escalated Complaints.

Educated and resolved (FQHC) Federal Qualified Health Center Billing and Dispute Complaints.

Educated and drove adoption of self-service tools (EDI, Provider Portal, EMR, etc.).

Conducted root cause analysis on claims adjudication or related issues via direct access to applicable tools

(eg; Omniflow).

Educated providers on service model to drive adoption and be the conduit to assist when service fails.

Drove providers to the standard process but supplements and supports as necessary.

Partnered internally with information exchange when WellCare has failed on service.

Conduit for provider issues that cross multiple platforms and/or result from integrations.

Obtained signed documentation via face-to-face provider visit when necessary in support of contracting lead by Network.

Development and re-credentialing lead by Credentialing Dept.

Scanned and submitted collected information.

Sept. 2012- Dec. 2014 The West Cancer Clinic, Memphis, TN Account Specialist II

Handled all State of Mississippi of BlueCross BlueShield of MS, and BlueCross of Tennessee Primary and Secondary Claims.

Advanced in Navigating and Operating Major Insurance Websites and EDI System Capario for electronic claims rejections and transmission.

Assessed proper payments and adjustments on individual bills or an entire patient account for accuracy of processing and take the appropriate action if done incorrectly, overpayments, underpayments and no payments.

Resolved billing issues/ question from both insurance carriers and patients by phone, fax and mail.

Processed Daily Mail.

Processed claims through third party vendor or online website.

Worked Aged Trial Balance Reports, Processed Credit Balance Report, for collection and evaluation of an entire patient accounts.

Interfaced with Coding, Medical records, and Patient Representative Departments

Created Training documents or manuals for new hires or training how-to’s- for claims processing as needed.

Jan.2012- Sept.2012 Health First Family Care, Memphis, TN Billing Specialist Team Lead

Prepared and submitted clean claims to various insurance companies either electronically or by paper.

Served as a liaison for patients’ questions, clerical staff, and insurance companies.

Identifies and resolves patient billing complaints. Prepares, reviews and sends patient statements

Evaluated patient’s financial status and established budget payment plans.

Followed and reported status of delinquent accounts.

Reviewed accounts for possible assignment and made recommendations to the Office Manager, also prepared information for the collection agency.

Performed daily backups on office computer system.

Managed various collection actions including contacting patients by phone, correcting and resubmitting claims to third party payers.

Participated in educational activities and attends monthly staff meetings.

Provided customer service to all patients with general questions and concerns and billing needs.

Trained and supervised new employees and externship students.

Established and created training manuals for new hires and students.

Initiated provider meetings and attended required seminars for best practice skills.

Trained staff to adhere and follow up with OSHA requirements in the absence of manager: follow all relevant OSHA safety and health standards. Found and corrected safety and health hazards.

Educated employees about chemical hazards through training, labels, alarms, color-coded systems, chemical information sheets and other methods.

Notified OSHA within 8 hours of a workplace fatality or when three or more workers are hospitalized or injury.

Provided required personal protective equipment at no cost to workers.

Maintained accurate records of work-related injuries and illnesses.

Received copies of test results done to find and measure hazards in the workplace.

Filed complaints with OSHA concerning inspection of hazardous workplaces as well as compliance. Apr.2008- Jan.2012 UT Medical Group,Inc. Memphis, TN Performance Improvement Analyst

Identified and reduced contract management risks.

Analyzed and processed complex and technically difficult claims by investigating and gathering information to determine the exposure on the claim.

Reviewed of individual workers comp patient claims accounts for proper reimbursement, including reporting and appealing improper payments.

Calculated and paid benefits due; approved and make timely claim payments and adjustments; and settled claims within designated authority level.

Assessed the claims and resolve the claims with evaluation.

Generated and monitored system reports to review accounts and ensure reimbursement is made according to contract/claims.

Followed up with worker comp claims to ensure that benefits are paid.

Trained new hire employees with their new job duties.

Analyze and report on the quality of work produced by insurance follow up employees.

Ensured claim files are properly documented and claims coding is correct and reported claims to the excess carrier.

Developed and deliver written training materials, classroom presentation and individuals.

Acted as primary source for all new hires and extern students while in training program.

Reviewed claims and invoices by assigned employees for accuracy and productivity. TECHNICAL SKILLS:

Proficient with Microsoft Office Tools (Works, Word, Excel, PowerPoint, Publisher).

Analysis

Collaboration

Project Management

Technical

Database

MS Office

Customer Service

SQL

Compliance

Effective keyboard and typing skills 100+ GWPM.

Quick Books

Data Entry

Proficient in Third Party Vendor Website, Emdeon, & Capario

Fluent in Major Healthcare Commercial and State Online Claim Processing Websites,

Educated with Medical Terminology

Proficient with ICD-9, CPT and HCPCS codes

Excellent Oral and Written Communication Skills

Experience with Medicare and Medicaid Billing, Claims and Policy and Procedures

Medical billing/collection practices

Business office procedures

TRAININGS:

EMR, Amazing Chart & EZ Claim Software

Trained in Various Hospital and Clinics Software, Medifax, Healthpro, Meditech, Passport

HIPPA Laws and Privacy Act in a Hospital and Physicians Setting

Completed Coaching Skills for Medical Practice Professionals /2.5 clocked hours

Fundamentals of Communication for Practice Managers/2.5 clocked hours

MPV/ Performance Management Course

Leading at the Speed of Trust/2.5 clocked hours

Change in a Physicians Practice/2.5 clocked hours

Basic Coding for Non-Coders/2.5 clocked hours

References Available Upon Request

Contact this candidate