Project Manager Customer Service
Resume:
TAMARA MONTGOMERY-DOWDELL
Jacksonville, Florida 32218
***-*** – 1000
*************@*****.***
PROFESSIONAL SUMMARY
• Versatile Insurance Professional with over thirteen years of insurance background including customer service, claims, project management, systems testing and implementation, sales and management.
• Extensive knowledge and experience with all lines of health insurance including: Health Maintenance Organization, Preferred Provider Organization, Medicare, Medicare Supplement, Medicare Advantage, Dental, Life, Accident, Disability and Annuities; Health Insurance applications including Imaginator, Diamond, Claims Repository, Medical Terminology, Corporate Medical Clearance Application (CMCA), Home Plan Aid, Legacy Systems, IVOS, Stellant, HIMR, MCS, Blue Squared, ITS, COSMOS, Med Impact, TriZetto Facets 4.2.1 – 4.8.1, QNXT 4.7, ICS, NASCO, Sharepoint, CentreVu, Siebel, E-talk/E-witness, Epitome, Icare, NPPES.
WORK EXPERIENCE
HP Technologies/ Kaiser Permanente Silver Spring, Maryland
Business Analyst (January 2012 – March 2012)
• Perform detailed benefits configuration functions (analysis, rationalization, data entry)for Xcelys 5.0.
• Document and track detailed system configuration changes.
Develop test scenarios that comply with ICD 10 format for regression, parallel and user acceptance testing.
• Track and lead resolution of detailed testing issues.
• Identify and coordinate with Project Manager to minimize testing risks.
• Utilized SQL to run queries needed to establish benefit tables in Xcelys.
Royale Class Consulting, Inc./ Universal American Houston, Texas
Business Analyst (November 2010 – December 2011)
• Used Benefits Matrix and Summary to set up HMO, POS, PPO and Medicare Plans in Trizetto Facets.
• Used components and rules to create product shells.
• Set up provider records and medical agreements for practitioners, facilities and provider groups.
• Established rules for inpatient and outpatient claims; set up provisions for discounts, risk withhold, stop loss and special pricing considerations.
• Designated parameters for ASC Multiple Procedures, Diagnostic Related Groups Rules, Exclusions, Procedure codes, Stop loss thresholds and Fee Schedules.
• Configured pricing profiles for provider agreements; defined capitated relationships.
• Created and executed Provider Agreement/Contract UAT test plans, test scenarios and test cases against Trizetto Facets 4.5.1 and Trizetto Facets 4.8.1.
• Conducted data maintenance including eligibility, provider, benefits, provider/facility agreements, member, claims and Networx pricing.
• Utilized Microsoft Word, Excel, Access and Visio to conduct maintenance and updates of various files and documentation.
Broadpath Healthcare Inc./ Health Plus Jacksonville, Florida
Facets Analyst (November 2009 – November 2010)
• Configured pricing for including Ambulatory Surgical Center Multiple Services Reduction, DRG claims, per diem, stop loss, manual pricing, percentage of allowed, flat rate, fee schedule reasonable and customary via NetworX Pricer/Modeler; Updated Products per updated Benefit Summary.
• Created and executed Provider Agreement/Contract Unit and SIT/UAT test plans, test scenarios and test cases against Trizetto Facets 4.5.1 upgrade.
• Utilized SQL to run queries needed to establish benefit tables in Facets.
Total Insurance Solutions, Inc./ Blue Cross Blue Shield of Florida Jacksonville, Florida
Facets Analyst (February 2007 – November 2009)
• Used Benefits Matrix and Summary to set up HMO, POS, PPO and Medicare Plans in Trizetto Facets.
• Administered and added explanation and user-defined Codes.
• Used components and rules to create product shells.
• Set up employer and Medicare groups in Trizetto Facets 4.2.1 to 4.4.1.
• Updated Service ID Descriptions application (SEDS) with plan services.
• Set up Service Rules, penalty parameters for the service rules, tiered copay, and deductible and coinsurance information.
• Used NetworX Pricer to link calculations to plan benefits and contract terms.
• Created and added components to models as required by the Plan.
• Created and executed Unit and SIT/UAT test plans, test scenarios and test cases against Trizetto Facets 4.41 implementation and upgrade.
Blue Cross Blue Shield of Florida Jacksonville, Florida
March 1999 – February 2007
Systems Analyst (July 2005 – February 2007)
• Provided Data Mapping solutions for conversion of data from Diamond to new DB2 platform.
• Provided Unit level testing support for Java, PL/SQL conversion to the HSD/Perot Diamond Client-950 Oracle claims processing system.
• Provided support in the System Design for capitation and Payment Processing.
• Performed all unit level testing for the accounts payable, general ledger modules of Diamond, capitation, price rules and provider contract module setup.
• Performed quality validation of configuration activities regarding institutional and professional provider contracts, benefits, authorizations, and/or claims/general configuration, system edit rules and fee schedules.
• Validated configuration test claims to ensure accuracy of data loaded into the Diamond system.
Operations Analyst (May 2004 – July 2005)
• Managed team members’ milestones and performance as compared to project plan, scope, budget, resources and schedule for Medicare Call Center.
• Performed quality audits on all 1-800 Call Centers via Etalk as a contractor for Centers for Medicare and Medicaid Services (CMS); calibrated weekly Quality Calls with CMS.
• Trained and supported Medicare Call Center Personnel staff towards the development of New Call Centers, Quality guidelines and expectations per Centers for Medicaid and Medicare Services.
• Provided consistent feedback and coaching to Call Center Representatives, Supervisors, Auditors and Management Personnel based on quality monitoring observations and identified trends.
• Developed and distributed ad hoc reporting daily, weekly and monthly for all assigned Call Centers.
LICENSE
PL-215 Florida Life, Health, Variable Annuity
EDUCATION
Columbia College - Bachelor of Science in Business Management 2012 Jacksonville, Florida
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