David Freshman's professional resume
Resume:
DAVID FRESHMAN
Aurora, CO 80013
Education
California State University, Northridge, 1986
Bachelor of Science degree -Business Administration-Marketing Option
Work Experience
Project Manager, Quality Management………………………………….Great-West Healthcare, Denver, Colorado
2006 – 2007
• Design and prepare Quality Mgmt Analytic reports for Senior Management
• Evaluate and trend Key Medical program indicators
• Initiate Analytic Report Projects for URAC, HEDIS & DMHC requirements
Senior Financial Analyst, Healthcare Economics ……………………….Great-West Healthcare, Denver, Colorado
2001-2006
• Produce financial reports that evaluate Provider Network Contracting and Claims Cost trends
• Design and prepare professional presentations for Senior Management
• Create Utilization and Quality Management reports
• Analyze Hospital Contracts for Senior Management Hospital Negotiations
• Analyze and Load Physician Fee Schedules for West Region
Network Management Contractor/Rep……………………………………….Pacificare Healthplans, Denver, Colorado
1999 - 2000
• Resolving claims, financial and eligibility issues with Physician Medical Groups
• Provided New Physician Group orientations
• Designed and provided statistical reports to facilitate and track claims issues
• Provided professional communications between Physician Groups and Healthplan Senior Management
• Negotiated, prepared and implemented Ancillary contracts.
Commercial Claims Department Unit Lead………………………..Pacificare Healthplans, Denver, Colorado
1997- 1999
• Delegation of claims responsibilities to a staff of eighteen claims examiners
• Implementation of productivity reports to management and staff
• Contract interpretation and timely resolution of claims issues for Member Services Team
• Training and back up claims auditing for examiners
• Adjudication of HMO Commercial claims for Ohio Region
Senior Claims Examiner …………………..Primera Healthcare, Denver, Colorado
1994 - 1997
• Adjudication of capitated risk / fee for service claims
• Compiled and presented instructional procedures for internal staff
• Audits, Reviews, and Authorizes payment and final disposition of claims in accurate / timely manner
• Handles incoming and outgoing phone inquiries regarding claims status, benefit determination and denial information
• Maintains claims adjudication system for contract allowances
Provider Relations Service Representative…………………..CareAmerica Healthplans, Woodland Hills, California
1992 - 1994
• Performed discount negotiations with non-participating providers
• Responsible for servicing and educating IPA provider networks
• Coordination of multiple projects
• Resolving and troubleshooting concerns of physician networks
• Delegation of projects for expedient resolution
• Handles incoming and outgoing phone inquiries regarding interested providers
Claims Examiner Level II ……………………………………CareAmerica Healthplans, Woodland Hills, California
1991 - 1993
• Responsible for processing HMO and PPO claims
• Review and authorizes payment and final disposition of claims in an accurate / timely manner
• Handles incoming and outgoing phone inquiries regarding claim status and benefit determination
• Maintains excellent customer service requirements
Claims Examiner …………………………………….Physical Therapy Provider Network, Woodland Hills, California
1989 -1991
• Processed, examined and entered claims for the entire PPO network
• Provided quality assurance testing
• Designed and produced statistical reports for claims management and marketing functions
• Provided communication liaison between PPO network and multiple insurance carriers
Administrative Assistant ……………………………….. American Screen, Los Angeles, California
1988 - 1989
• Handled cost and information research
• Performed word processing and file editing
• Completed order entry, data verification and data entry
Customer Sales/ Service Representative …………….. Alfred Publishing, Los Angeles, California
1986 - 1987
• Researched and maintained information for customer service needs
• Accomplished all order entry
• Completed data maintenance and input for in-house sales statistics
Retail Store Manager ………………………. General Nutrition Corporation, Los Angeles, California
1984 - 1985
• Established a new retail outlet
• Interviewed, hired and trained sales team
• Organized and implemented promotional displays
• Planned, ordered and maintained merchandise inventory
• Provided budgetary and cash management
Marketing Analyst/ Machine Operator …………………………. Banner Gelatin Products Corporation, Chatsworth, California
1974 - 1984
• Performed new product research for Marketing Division
• Maintained accounting database, including A/P, A/R, invoices and purchase orders
• Utilized and implemented production operations
**References furnished upon request
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