Data Analytics & Claims Optimization Specialist

* * * * * A D Y T H A T C H E R D R . M U R F R E E S B O R O, T N 3 7 1 2 9

***- ***- * * * 3 R E Y . J E S S 2 2 @ G M A I L . C OM J E S S I C A R E Y N O L D S

OBJECTIVE

To obtain a challenging position which utilizes my strong training background, client liaison roles, research and analytical ability to further build my knowledge base. SUMMARY OF QUALIFICATIONS

Strong analytical and problem solving skills

Ability to adjudicate claims

Strong research background

Experienced with contractual auditing and medical terminology

Team Mentor and Liaison

Proficient in Excel, Word, Safari, Aetna systems, Optumcare systems, Claim Miner and SQL code reading

WORK EXPERIENCE

September 2023- May 2025, Optum

Recovery Resolution Consultant

Identify waste combinatorics and drug overpayments for both Aetna and Optumcare clients

Minimize defects in production analytics through thorough QA of the analytics

Increase client trend approval percentages

Submit trend request approvals to the client for newly identified trends January 2022- September 2023, Optum

PI Non-Clinical OPS

Assist with contracts and duplicate diversions for Aetna

Increase client trend approval percentages

Minimize defects in production analytics through thorough QA of analytics prior to deployment.

Identify and execute other solutions that have a positive impact on the inventory delivered to our customers

Minimize defects in production analytics through thorough QA of analytics prior to deployment

January 2016-June 2022, Optum

Senior Business Analyst- Optum

Awarded Superhero in 2016 for stellar performance in claims analytics while training all new hires and offshore.

Analyze, review, forecast and trend complex data

Present analysis and recommendations for operational and business review/planning

Support short and long term operational/strategic business activities through analysis

Develop automations for client production trends and screen scrapes for waste reduction

Develop, recommend and implement business solutions through research and analysis of data and business processes

June 2013-January 2016, Optum

Senior Recovery Resolution Analyst

Analyze claims by researching provider contracts and polices to determine possible overpayment of claims

Examine, assess and document business operations and procedures to ensure data integrity, data security and process optimization

Ensure adherence to state and federal compliance polices, reimbursement policies and contract compliance

Create detailed refund reasons and templates to ensure all viable information is included for overpaid claims to be recovered

Use pertinent data and facts to identify and solve a wide range of problems within the claims and contracting side of the business

Adjudicate claims based on contract allowable, coordination of benefits and duplicate payments, etc.

Mentor and act as a liaison to all new hires and our offshore team through training and web conference calls to ensure they have all the necessary tools and knowledge to complete their daily tasks.

November 2008 –June 2013, Optum

Business Account Manager

Contact providers on behalf of health insurance companies to resolve overpayments

Analyze and interpret contracts between the insurance companies and the provider

Conduct training classes for the Recovery Department to arm the analysts with useful information to provide additional refund reason talk offs

Provide support for Recovery Department by researching, investigating and auditing claims to increase recovery yields

Analyze information to provide recommendations to reduce research

Utilize the client system in order to perform internal investigations on accounts and provide documentation to support collections of a refund

Develop and implement new processes for research May 2006-November 2008, Verizon Wireless

Customer Service Representative

Provided a courteous customer service experience

Maintained confidential employee and business accounts

Worked independently and communicated efficiently February 2004-January 2006, Five Oaks Country Club Assistant Manager

Conducted daily staff and weekly management meetings

Budget planning and developed spreadsheets to monitor outcomes

Interviewed, trained and coached new hires

Produced weekly schedules and payroll.

Conducted all administrative duties as requested. REFERENCES

Available upon request

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