VICKI L. TAYLOR-JOHNSON

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

COMPTON, CA. 90220

(C) 310-***-****

adzhq2@r.postjobfree.com

Summary of Qualifications

Proactive leader and motivator with the ability to create measurable project plans, provide focus and control to meet deadlines.

PC proficient, including Microsoft Office 2000 applications, medical and dental terminology, ICD-10 and Current Procedural Terminology (CPT) codes, IDX Claims Adjudication System, Access Database, Macess Doc Flo system, Claims Portal, QNXT, CCA and NCIS Inquiry tool

Excellent attention to detail, which include problem solving, analytical, verbal and written communication skills.

Enjoys and accepts challenges with enthusiasm, which allows me to work collaboratively and independently in a team environment.

Thrive in a fast paced team-oriented environment that requires flexibility and quick response to changing priorities; multi-tasked with highly developed organizational skills.

Work Experience

Mar 2018 – Present

Healthcare Partners Medical Group/Optum

El Segundo, CA

Business Analyst II / NCIS

Direct IMCS contact for claim/EDI inquiries

Research and provide timely status updates

Track and trend new and recurring issues

Identify and report any barriers and challenges in resolving issues

Report scope of impact and coordinate timely reprocessing of claims

Communicate resolution to all appropriate entities

Perform vendor site visits as needed

Analyze and define requirements through functional research, which includes assessment and data gathering that lie outside of the required completion dates to appropriate levels of management

Dec 2016 – Mar 2018

L.A. Care Health plan

Los Angeles, CA

Senior Quality Configuration Analyst

Test, validation and quality assurance of business requirements to help ensure the timely, high quality configuration of the systems, in support of systems implementations/ upgrades and organizational initiatives and projects.

Collaborates closely with peers and management within the department

Ensure that the most complex data sets are analyzed and well thought out, recommendations for improvements are presented and implemented where warranted

Facilitates the tracking of configuration changes and auditing the results of those changes; and the timely, appropriate maintenance, update, and distribution of the systems release notes.

Collaborates with Enterprise Configuration management and peer on findings from the testing, recommended configuration changes.

April 2009 – Dec 2016

DaVita/Healthcare Partners Medical Group

El Segundo, CA

Business Analyst II

Analyze and define requirements through functional research, which includes assessment and data gathering that lie outside of the required completion dates to appropriate levels of management.

Monitor provider’s claims submissions to ensure their claims are submitted at 75% or above electronically; including Hierarchical Condition Category (HCC).

Review and report discrepancies in system design or system set-up; which includes collaborating with Information Systems team to understand and develop business requirements and translates them into technical specifications.

Assist in the design and implementation of business processes, system interfaces, system testing, issue management, scheduling, documentation, training, system administration, status meeting and all other project-related proceedings.

Participate in the implementation of new features for an application; claims portal.

Travel to provider’s office to resolve technical issue with on-line portal, billing issues wording; training to properly submit claims by print image or 837 Ansi and resolving issues the provider is disputing regarding electronic claims in a timely manner.

Liaison for providers that have electronic submission disputes with Office Ally.

Perform additional duties as assigned, which includes performing routine testing to keep Claim department applications functioning, testing updates to data dictionaries, creating and testing vendor contracts, assisting with system upgrades, resolving electronic claims filing errors.

Represent the department Director at management level meetings reporting the team’s current productivity and project status.

Supported the Business Recovery Unit as an Observation Analyst to access and make recommendations for improvement in the pursuit and proper recovery of overpayments of claims.

February 2004 – April 2009

Healthcare Partners Medical Group

Torrance, CA

Claims Examiner III – Technical Services

Quality control of various billing systems, including testing revenue codes, ICD-10 and CPT codes to confirm that the claims were submitted correctly.

Assisted in creating the hospital template; which included diagnosis codes, procedure codes and revenue codes for hospital contracts.

Review Division of Financial Responsibility (DOFR), contracts and fee schedules to determine who is responsible for payment.

Respond to and resolve provider claims inquires and apply resolution in a timely manner.

Researched revenue and procedure codes, which includes add on codes, unbundling, stand-alone to assure provider is billing correctly.

Reviewed, analyzed and tested claims to assure system was configured correctly.

Collaborating with the Contracting department to assure the language and set-up of the contracts are configured correctly to reassure proper payment of provider’s claims.

May 1999 - February 2004

Healthcare Partners Medical Group

Torrance, CA

Claims Examiner III – Hospital Unit

Analyzed, researched, and adjudicated UB92 high dollar claims

Process claims based upon contractual agreements, health plan division of responsibility, applicable legislature, claims guidelines and client policies and procedures.

Respond to and resolve provider, customer claims appeals and grievances and apply resolution in a timely fashion via written correspondence or telephones.

Review DOFR, contracts and fee schedules to determine responsible party

Monitors quality and productivity standards, and comply with company administrative guidelines.

July 1998 - May 1999

Prudential Healthcare

Los Angeles, CA.

Customer Services Representative

Conversations with customers and providers regarding claim payment issues

Collaborating with Health Plans to verify member eligibility.

Research follow-ups that include solving claim issues, quoting benefits and updating member Coordination of Benefits (COB) files.

June 1996 - June 1998

AHI Healthcare Systems

Long Beach, CA.

Vertexer (Data Entry Examiner)

Compiled, sorted and entered data from source documents.

Identified and researched member information for eligibility accuracy.

Manually entered claims into Rumba claims system.

Education

1995-1995

United Education Institute

1998-1998

Cerritos Community College

February 2014 – August 2019

University of Phoenix –Bachelor’s Degree, Business Management

Leadership

Toastmasters International Member El Segundo Toastmasters Club, Treasurer.

Responsible for the budget, accounting, and membership documentation.

Maintain club’s financial policies, procedures and controls.

References

Available upon request

Contact this candidate