Business Analyst Accounts Receivable

James Swift

Blakely, PA ***** 570-***-**** **********@*******.*** linkedin.com/in/jim-swift-0209417a

BUSINESS ANALYST

Results driven professional with 20 years of experience in the insurance industry, skilled in claims, accounts receivable manager, and business project advisor working with dynamic teams to achieve project goals on time and with great accuracy.

Core Competencies

Business Process Analysis & Optimization Claims Management & Resolution

SQL & SAS Data Reporting & Analysis Healthcare & Insurance Operations

Stakeholder & Client Relationship Management Cross-Functional Team Collaboration

Project Lifecycle Management (Waterfall/Agile) Operational Risk Identification & Mitigation

System Testing & Validation (Facets, TOAD, CED) Dashboard Creation & Performance Metrics

Incident & Issue Management Root Cause Analysis & Troubleshooting

Training & Mentorship of Team Members Contract & Provider Data Reconciliation

Regulatory & Audit Compliance Support

EXPERIENCE

Business Project Advisor June 2022 - May 2025

FNS Reporting Team - Writing SQL in SAS to pull reports per request. Pulling bi-monthly Evicore reports and sending off to other departments to determine discrepancies and fallout. Working daily incident reports that come into the queue and submitting tickets to create more capacity so jobs can run without incident.

Operations Lead Analyst (RAP AOM) May 2017 - June 2022

Reimbursement Alternative Payment Inquiry and Delivery - Assets Operations Management (RAPID AOM)

Led operational analysis and validation of payment accuracy for Collaborative and Capitation programs by executing system testing, data reconciliation, and root cause resolution.

Effectively tested, analyzed and validated accurate payments were distributed as it relates to Collaborative and Capitation programs. Supported release delivery activities, partnered with Production Support and Agile Product Owners and collaborated with IT Leadership and Production Support. Utilized critical thinking skills to meet business needs. Ensured Issues/risks/barriers were clearly documented, resolved and / or escalated appropriately. Supported operational model improvement activities. Participated in project requirements sessions as an operations SME.

Tested scripts to validate systems were updated and working correctly. Worked intakes to resolve fallout. If fallout was occurring due to contracts or eligibility not loaded correctly, sent to have these PIDS replayed so they would be correct. Worked with Facets, CED and SANP to verify systems were loaded correctly. Worked with TOAD and SAS to pull reports verifying systems are aligning with CED and Facets.

Worked on Asset Monitoring Reporting to validate jobs that were run weekly. Put together monthly dashboards containing all jobs that were run to validate timeliness and any issues that were seen and any trends that needed to be resolved. Conducted weekly and monthly meetings with management to go over reports to determine best practices on fixing job runs to make them more efficient.

Worked weekly Asset Monitoring reports to determine long run times for jobs, how many transactions each job produces, and looked for any trends that could be resolved.

Produced a monthly Dashboard with all stats from the weekly Asset Monitoring reports and produced results to upper management.

Prepared Inventory Data reports. Put together reports to determine how many projects had been worked by the team and how long they took to complete.

Provided Cust Load reporting. Pulling reports from the system to see any trends with job runs. Tried to determine if systems were working to alleviate the amount of fallout.

Purged/Archived reports. Pulled weekly reports for the purge/archive to determine if all data was accurate.

James Swift **********@*******.*** Page 2

HCP 9/06/2004 - May 2017

Accounts Receivable Manager, October 2014 - May 2017

Handled Swedish and Providence hospitals in the Alaska, Oregon, and Washington markets. Served as the liaison between the hospital and Cigna, handling any issue that the hospital has, making sure claims were paying correctly, providers loaded correctly, and systems were updated with the correct contract language.

Attended weekly and monthly meetings with the hospital reviewing any issues they were having. Educated them on issues identified. To determine what steps would be required to resolve them. Reviewed spreadsheets that the hcp had submitted and reviewed claims to make sure they were allowing correctly or sending them to be adjusted if needed.

Checked provider systems to make sure provides were loaded correctly; trained new hires on Proclaim; looked up provider contracts and made sure the contract matched systems; performed Contract Intent Review audits for assigned hospitals, going over claims issues and contract, resolving issues on both Cigna's and the hospital’s side.

AR Associate, 1/23/2012 - October 2014

Provided customer service to the providers, Worked with AR Management team researching claims and determined if they were paid correctly. Had provider contracts updated in the system, worked spreadsheets.

Client Audit Coordinator, 10/11/2010 - 1/22/2012

Assured Cigna passed client audits in order to keep our clients happy and keeping their business. Greeted outside auditors, reviewing claims to make sure they were paid correctly, setting up meetings to discuss possible errors and error trends with management, sales, and csp's, auditing claims, reviewing provider contracts. Determined how a claim was priced. Pulled reports on high dollar claims. Worked with different areas in determining how a claim was paid, including Net2Ops, High Dollar Cost team, and Accent.

Quality Review/SR Associate, 1/19/2009 - 10/08/2010

Audited claims for the new hire classes, answering questions for the new hire classes, processing claims and correcting errors, working manual reports on Quality Calls to discuss ways to improve claim accuracy. For the PrePay team, analyzed edits currently on file. If something needed to be changed or made clearer to improve claim accuracy, took the proper steps to have them corrected.

Correspondence, 9/06/2004 - 1/16/2009

Senior Benefit Analyst/Correspondence. Analyzed and processed various types of medical claims and responded to incoming correspondence from providers and members. Worked on Excel reports daily, maintaining a high accuracy and processing efficiency... worked as a SME for the Correspondence team from May 19-May 23, 2008 in managers absence. Helped answer questions that the team had and took referred complex questions to management.

EDUCATION

Bachelor of Science (BS) in Economics

Penn State University

Skills

Proclaim PMHS Facets Payor Solutions PPN Excel Word Microsoft Outlook Email Conference Calls Training Appeals Authorizations Provider Workbench CART Reports Provider Contracts TOAD SAS Reimbursement Manager CED SANP ALM CCMI SQL Agile/Kanban JIRA

HCPM/PTDM/CPF/PRDS QNXT

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