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| Desired Industry: Insurance |
SpiderID: 25011 |
| Desired Job Location: Tampa, Florida |
Date Posted: 2/14/2009 |
| Type of Position: Contractor |
Availability Date: 02/16/2009 |
| Desired Wage: 70K |
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U.S. Work Authorization: Yes |
| Job Level: Management (Manager, Director) |
Willing to Travel: |
| Highest Degree Attained: Other |
Willing to Relocate: No |
Objective:
To utilize my knowledge, experience and ability for the benefit of my employer, employer's clients and myself
Experience:
I possess 15 years in the health insurance industry including, but not limited to, all areas of Operations and Compliance. I specialize in claim processing, administration, regulatory audit, HEDIS and NCQA audit and accreditation, appeals & grievance, benefit analysis, benefit design and benefit programming.
I have substantial knowledge of Medicare regulatory requirements and coverage rules and Medicaid plans in several states. I have been involved with a start up Medicare/Medicaid plan in Florida that has grown from zero members to over 50,000 since May 2005. The plan has grown to include many types of Medicare plans (managed care, managed care with POS and Private Fee-for-Service) and Florida Medicaid (Reform and Non-Reform).
I have been an integral part in their growth and development and assisted them in the completion, submission and subsequent approval of their Medicare and Medicaid licensure and contracts and worked closely with system programmers to develop system enhancements to increase processing accuracy and auto-adjudication within their claim system.
I have been an integral part of several carrier's HEDIS, CMS and NCQA audit preparations and have attended interviews with their auditors as both a Compliance expert and Claims expert.
I specialize in root cause analysis and focus heavily on system functionality and issue resolution.
I am fully knowledgeable of both Medicare and Medicaid payment methodologies and many of the Medicare IPPS/OPPS pricing applications currently available for DRG, APC, SNF and other payment methods and have assisted in the system integration of these products in several claim systems.
I have in depth knowledge of provider contracting and the system configuration of contract reimbursement rules and have worked closely with service providers to resolve A/R issues to the satisfaction of the service provider and the plan.
I am fully proficient in all areas of claim coding and billing including HIPAA code set compliance, NPI utilization, CLIA, Medicare RVU file interpretation, Medicare NCCI Edits and inbound/outbound 835/837 file formats.
Education:
Associate of Arts (Pre-Med) Degree not completed due to financial issues and family emergency(s)
Skills:
Fully proficient in MS Word, Excel, Seagate Crystal, TOAD SQL, Power Point and type in excess of 65 WPM. I have excellent communication skills, both written and verbal and take pride in producing quality results.
Reference:
Available upon request.
Candidate Contact Information:
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