Customer Service Project Manager

Stephanie Smith

*** ****** ***** **.

Bolingbrook IL, 60490

Phone: 561-***-****

Email: **********@*****.***

Objective

Obtain a challenging and rewarding position, within a solid, progressive staff setting that best. utilizes my experiences and training with opportunity for personal and professional development. within any corporate setting.

Strengths and Knowledges

Creative problem solver and very analytical team player who is successful in meeting deadlines, and handling pressure……at the same provide excellent customer service, reliable and adaptable; take initiative and readily to accept new responsibilities and challenges.

Demonstrate attention to detail, strong organization skills, time management skills, strong. analytical background, with strong presentation, great interpretation, writing and oral skills,

Committed to quality and a high production work environment. Maintained 99.8% accuracy based on the service observance performed.

Great knowledge in Microsoft office products, Word, Outlook, Excel, Office XP, Microsoft Access, and PowerPoint Presentation.

Experience with various Hospital Patient Access systems, Account Receivable systems, and EMR systems which includes IRMA, including correcting Quarterly AHCA reports, Safari and

FACS for accounts receivable, ALLSCRIPTS, PBAR, MCKESSON, EPIC, MEDITECH, Cerner, CERNER CRANEWARE, and AS400

Experience in Analyzing pricing for approved fee schedule on adjudicated and non-adjudicated, paper claims for Manage Care, disability claims, claims, and Rx Claims, Medicare and Medicaid, HMO, PPO, and third-party claims.

Possess great knowledge in ICD-9, ICD10 Diagnosis codes, Center of Medicare & Medicaid rules of MS-DRG, CPT and HCPCS codes. Knowledge of pricing physician and outpatient fee schedule and Inpatient hospital claims with Webstrat pricing, Encoder Pro for DRG, APC, and ASC pricing.

Experienced in utilizing Knowledge Library Reimbursement policy for to provide education on ICES Edits claim denial, Claim-Xtend, DRG Outliers for inpatient claims, Sam Edits, TRACR, Fraud abuse and Subrogation.

Provide excellent experience in different systems and applications to perform all job functions for, Third Party Insurance such as WellPoint, UNICARE, ANTHEM, AND UNITED HEALTHCARE SYSTEM EXPERIENCE AND APPLICATIONS

DIAMOND, UNET, ISET, IDARS,CPW,COSMOS,CSP FACETS, OHBS FACETS,NICE, CLAIMFACTS, 2.0, PPO- ONE,SAFARI, UDW, OPTUM ARO,COSMOS, FILENET 2.0, Hanstar, Sam Edit Database, PC-ORS, NDM, EMPTORIS, MACESS, DCT, CAID, WEBSTRACT RX claim, RXCLAIM Suite, AS400, AVAILITY, NAVINET, EDSS, RPU2U,CRT,TEAMTRACK, MIC, CES REPORTING,ODAR, EMR, SHAREPOINTS, QNXT and Dynamo Work Experience

Aetna/CVS

Senior Network Relations Analyst 10/17/2021-04/14/2023

• Was the primary resource for assigned, high profile provider or groups (i.e. local, individual providers, small groups/systems) establish, oversee, and maintain positive relationships by assisting with or responding to complex issues regarding policies and procedures, plan design, contract language, service, claims or compensation issues, and provider education needs.

• Optimizes interactions with assigned providers and internal business partners to establish and maintain productive, professional relationships.

• Monitors service capabilities and collaborates cross-functionally to ensure that the needs of the Providers are met.

• Escalated issues related but not limited to, claim payment, contract interpretation or parameters, and accuracy of provider contract or Roster Manage for demographic updates are resolved.

• Supports or assists with submittal of Universal Rosters for the Database Management team, and Contract Team.

• Performs credentialing verification when needed with the State of Illinois for eligibility purposes.

• Educates providers as needed to ensure compliance with contract policies and parameters, plan design, compensation process, technology, and contract interpretation language.

• Meets with key providers periodically to ensure service levels are meeting expectations.

• Manages the development of agenda, validates material from the State and facilitates external provider meetings, cross functionally on the implementation of large provider systems, to manage cost drivers and execute specific cost initiatives to support business and to identify trends and enlist assistance in provider resolution.

• Assist with Network Management and Contracting for standard provider recruitment, contracting, reconciliation outreaches and assist with more complex contracting and discussions as needed by business segment.

Aetna/CVS

Grievance and Appeal Consultant 07/06/2020- 10/16/2021

• Independently review and evaluate appeal and grievance requests to identify and classify member and provider appeals, using internal systems, determine eligibility, benefits, and prior activity related to the claims, payment or service in question.

• Make outreaches to Providers or Members in regarding Appeal or Grievance received to acknowledge the case.

• Independently conduct thorough investigations of all member and provider correspondence by analyzing all the issues presented and obtaining responses and information from internal and external entities. Validate the responses to ensure they address the issues and are supported by any contract stipulations, regulations, etc. as applicable.

• Prepares cases for Medical Directors internal and external review detailing the findings of their investigation for consideration in the plan’s determination. Make recommendations on administrative decisions by preparing detailed case.

• Summaries and reviewing all applicable benefit and contract materials. Present findings and recommendations to appropriate parties for sign-off. Make critical decisions regarding research and investigation to appropriately resolve all inquiries.

• Serve as liaison with Aetna Better Health of Illinois departments, vendors of specialties, delegated entities, medical groups, hospitals and in and out of network physicians to ensure timely resolution of cases.

• Follow-up team members on audits that were conducted quarterly and assist with error changes.

• Monitor daily and weekly pending reports and personal worklists, ensuring internal and regulatory timeframes are met.

• Facilitate meetings for appeals related to outside Vendors on issues that’s delaying the process of closure of a case.

• Independently prepare well written, customized responses to all correspondence that appropriately and completely address the complainant’s issues and are structurally accurate.

• Ensured responses are completed within the applicable regulatory timeframe. United Healthcare

Senior Reporting Analyst (08/5/2018-12/2/2019)

• Developed reports by utilizing SQL, Galaxy, and Toad Database for a variety of analyses, to include, but not limited to, trend analysis, network evaluation, facility and ancillary contract evaluation, all claim data accuracy, staffing models and sales and enrollment.

• Creates ad hoc files and reports to support analyses, such as contracting issues, clinical, ancillary or environmental trends, and sales.

• Work with Excel Spreadsheets importing data from selected tables and exporting to spreadsheets and provides written and oral communications on generated reports via SharePoint in which the request was retrieved or PowerPoint via the client request.

• Liaison between project managers, internal and external clients of variety analyses, to include, but not limited to, trend analysis, network evaluation, facility and ancillary contract evaluation, all claim data accuracy, staffing models and sales and enrollment. UnitedHealth Group/ United Networks

Senior Provider Ancillary Advocate/Network Management (03/20/2016-08/4/2018)

Build and maintain positive professional business relationships with all Providers, health plan contacts, ancillary providers and internal staff to work efficiently and effectively manage contracts for all of business, by initiating walk-in physician office visit, emails, via phone, and Web Ex meetings to solve more complex issues on Reimbursement policies, new provider contracts misinterpretations, Retro contract loads, and contract renewals.

Serve as a subject matter expert resource for Provider Advocates and Network Account Managers by using existing procedures and facts to solve routine problems or conduct routine analyses.

Analyze claims that were considered as a failure in UHC service model and provide root cause analysis of a claim issues, provide directives to adjusters for all lines of business in reprocessing claims that were inappropriately denied or requesting additional information on UNET, COSMOS, DIAMOND, and CSP Facets platform.

Coordinate with Internal Business Partners to resolve service issues such as: Claims Project Management, Contract Management system (CCI), Network Database, etc. and promptly escalate and initiate projects to be expedited for claim reconsideration of a Known Service issue, trends of claims processing issues, authorization denials, or any erroneous denials.

Provides education and resolution of findings to contracted providers, Provider Relations Reps and Network Management as needed.

Support and participate in Service Model process and performance improvement activities to ensure our providers are excising the correct paths for reconsideration and appeal.

Sending updates through our internal process system with accurate information that resulted in resolutions of the provider’s expectations in a reasonable TAT for updates and follow-up responses to the providers.

UnitedHealth Group (05/05/2014 03/19/2016)

Senior Recovery Resolution Analyst

Review claims pre-payment to validate the accuracy of the payment by examining Contracts attached to DRG’s, APCs, Fee for Service rates and document business operations and procedures to ensure data integrity, data security and process optimization with Investigation determination pursue recoveries and payables on subrogation claims, FWA Claims, and Flagged High Dollar claims.

Develop and maintain positive professional business relationships with health plan contacts, ancillary providers, and internal staff to work efficiently and effectively managing all lines of business, while conducting Contract Audits on front end claims.

Compile and analyze data to identify the root cause analysis to provide feedback to internal partners, hospital and professional provider by conducting Web Ex meetings and conference calls to solve more complex issues on Reimbursement policies, new provider contracts misinterpretations, Retro contract loads, and contract renewals with CMS Medicare and Medicaid Billing payment rules.

Ensure to state and federal compliance policies, reimbursement policies, and contract compliance are being followed per High Dollar Claim by Utilizing knowledge and various resources related to payment rules, benefits, contracts (provider, state, CMS), pricing configuration, coding anomalies, authorization requirements, operational processes, and other factors that affect claim payment.

Effectively communicate any claim errors to the processor with directive on correcting the errors.

United Healthcare/ Provider Network

Provider Relations Rep (3/25/2012- 04/11/2014)

• Serve as a subject matter expert resource for Provider Advocates and Network Account Managers by using existing procedures and facts to solve routine problems or conduct routine analyses.

• Analyze claims that were considered as a failure in UHC service model and provide root cause analysis of a claim issues, provide directives to adjusters for all lines of business in reprocessing claims that was inappropriately denied or requesting additional information on UNET, COSMOS, DIAMOND, and CSP Facets platform.

• Coordinate with Internal Business Partners to resolve service issues such as: Claims Project Management, Provider Appeal

• and Grievances, Contract Database, Roster Management and Network Data Management etc.

• Manage escalations that are being transferred to our escalation team for resolution of denial errors, authorization denials,

• and any other erroneous denials of a Known Service issue and trends of claims processing issues.

• Provide education to providers as well as Provider Advocates and Network Management of my Final Resolution.

• Support and participate in Service Model process and performance improvement activities to ensure our providers are excising the correct paths for reconsideration and appeal.

• Sending updates through our internal process system with accurate information that resulted in resolution of the provider’s expectations in a reasonable TAT for updates and follow-up responses to the providers.

UnitedHealth Group/Medicare and Retirement (09/20/2010-03/25/2012) Senior Recovery Claim Resolution Analyst, Sam Edit, Fraud, Waste and Abuse, Subrogation

Working with Analyzing Medicare and Retirement and processing TRACR claims for recovery of overpayment for participating and non-Participating providers on the Cosmos, and CSP Platforms.

Retrieved issues via SharePoint through UHC internal partners and initiating recovery of overpayments with interest and clearing appropriate reviews.

Analyzed and identified trends of provider billing and claim processing that resulted in overpayments.

Initiating the recovery of overpayment through the tracer system with ensuring state and federal guidelines for reimbursement policies and contracts are complying and followed that may include interest.

Setting up ODAR request for providers within the Negative Payee Status in which we are unable to recover funds do to the provider not having available funds and they are participating providers.

Working with Sam Edits approving and correcting claims in which has been processed in error based on all Edit rules.

Work efficiently in Provider and Member Service SharePoint, Subrogation, Fraud, Waste and Abuse ensuring all aspects of recovery is researched and done.

Initiating pricing through WEBSTRACT pricing for provider contract underpayment dispute. AHC Convergent Inc. / Boca Raton, FL (09/2009-09/2010) Hospital Claim Analyst/Appeal and Grievance Specialist

• Working with the account receivable department and customer service department of our client retrieving overpayments and adjusting underpaid Medicare, PPO and HMO claims.

• Create offline appeal letters and explanation of benefits to our clients, reflecting claim adjustment processing and refunds.

• Process third party billing of HCFA and UB92 claims, including coordination of benefits of Medicare, HMO, PPO and Medicaid benefits by paper for more complex claims and adjudication of claims.

• Ensuring maximum expectation of reimbursement for the healthcare providers and ensuring billing is correct for proper processing of the claim. Utilizing my writing abilities, with representation of appeal letters, for all level of denials that will assure reprocessing of in appropriately denied claims were released for payment.

• Working on the behalf of the hospital contacting Third Party payers for underpaid claims and posting payment from insurance companies and patients.

• Analyzing claims and investigating the reason for underpayment and or the reason why the claim denied. Utilize my customer service skills by placing phone calls to insurance Managed care companies for payment pursuits

• Generate appeal letters on behalf of the Hospital in argument and assurance that we are due additional money and demanding payment in full immediately especially for payment paid under the contracted amount.

OptumHealth /Lisle IL Telecommute

Documentation Specialist/ Senior Customer Rep (04/23/2007-06/20/2008)

• Assist Project manager with Overall Project Manager responsibilities for new business as a UAT tester and Post testing once the Employer’s business has went live for processing and Implementing plan system testing for new onboard Employer’s Group Plans, verifying Group coverages via IBAAG (Benefits Verification) used this system to verify readiness on going live for processing of new business.

• Setting up electronic eligibility files for eligible transplant patients working closely with Case Managers, Account Managers, Benefit Configuration and Notification department • Keeping track of received data report and source documents, with detailed test status.

• Enters alphabetic, numeric or symbolic data from source documents into a computer-based application (s, Facets following the format displayed on the screen. Ensure accuracy at all-time especially with Eligibility of clients, educate group plan account manager on reimbursement policies and drives adoption of self-service tools and provide support. Unicare Life and Health/Anthem, Chicago IL

Client Service Associate/Claim Adjuster (10/1999-12/2005)

Worked under limited supervision to resolve provider issues using independent judgments within guidelines., serves as the

initial and main point of contact “Between” the Employer Company, Insures, current and potential members, beneficiaries, providers, employers, and agents in a Call center environment.

Answered provider calls in regard to Negative Balance Reports and claim issues. Mid -High Dollar claim audits for recovery on Hospital claim payment to release on claims processed by adjusters with dollar limitations.

Maintained Monthly Analysis of outstanding refunds to be posted within 14 days before another generated letter was sent to providers and members for overpayments.

Work with the accounts payable department (Claims Team) and customer service department of our client retrieving Overpayments and adjusting underpaid PPO and HMO claims. Process third party billing of HCFA and UB92 claims, including coordination of Medicare, HMO, PPO and Medicaid benefits by paper for more complex claims and adjudication EDI of claims.

Create offline letters and explanation of benefits to our clients, reflecting claim adjustment processing and refunds. Work on the designed Hanstar system using appropriate professional and hospital fees scheduling to claims. Maintained the Stop Pay Procedures Manual when appropriate, researched and resolved problems related to no match checks for the providers and applied refunds for overpayment to account that was overpaid to providers.

Provide timely and accurate resolution of inquiries analyzing issues regarding benefits provider contracts, pricing, processing issues of the member account, and responsible for achieving the goal of 20-second answer speed.

Resolve all Providers’ issues that were gathered on Physician and Hospital visit for reconsideration or possible appeal directives.

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