Alyssa Sheneman

Provides advanced professional input to complex Data measurement & Reporting assignments/ projects. Provides analytical and operational reporting, business performance measurement and management dashboards, and fulfills data and measurement requests from business partners. Responsible for managing advanced data/analytics projects that are used to develop actionable insights and recommendation. Supports and provides direction to more junior professional. Works autonomously, only requiring expert level technical support from others. Exercises judgement in the evaluation, selection, and adaption of both standard and complex techniques and procedures. Utilizes in depth professional knowledge and acumen to develop models and procedures, and monitor trends, within Data Measurement & Reporting.

Provides analytical support during the sales process for network provider geographic availability and disruption analyses and Request for Proposal (RFP)

• Developed a QA database in Access to ensure data is clean prior to doing a system audit that will make updates based on the output
• Ensures data integrity and up to date information in provider databases and technical documentation
• Receives network reporting requests from provider contracting and sales
• Develops, modifies, maintains, and delivers routine to moderately complex custom reports from typically a singular data source
• Compares and summarizes the customer group’s current network to the Company’s and other networks sources
• Reports on network adequacy and accessibility, plotting proximity of providers to homes of members in customer group
• Interprets data and analyzes results for Request for Proposal (RFP)
• Ensures data integrity of provider databases
• Conducts data scrubs and organizes data to maximize opportunities for specialty analyses and improve quality of data
• Acquires and incorporates external data from other network sources the Company uses to maintain up to date databases
• Ensures technical documentation is up to date for various systems, services and business policies and processes, including databases and reporting procedures
• Keeps up to date on Company products and services, internal movements, industry trends, regulations and related.

Provides administrative support to the Provider Credentialing and Data Management departments

• Maintains electronic file and record keeping systems and administrative processes and procedures
• Acts as a contact between Medical Mutual and delegated / non delegated hospital systems
• Create and manage cooperative working relationships with providers
• Performs data analysis on large excel rosters and formats to process
• Assists Contracting Representative in resolving credentialing issues or provider notifications
• Assists in trending claim issues/resolution
• Complies with all CMS guidelines.

Responsible for the initial and ongoing practitioner, provider, and organization data entry and credentialing into the various modules of the Provider Data Management Systems

• Ensure compliance with standards set by individual states, federal and accrediting organizations
• Accurately verifies and enters information into the Provider Data Management System Adds network products to credentialed providers
• Meets metric expectations as required by productivity and quality
• 100% for productivity 99% for quality
• Process claims daily

Verify and provide insurance benefits for home care services, home infusion services, and respiratory services. Worked with all insurance plans including Medicare/Medicaid/PPO/HMO

• Work denied claims and send for reprocessing
• Work with managed care insurance groups on identifying trends for claims issues and reprocessing
• Ensure all billing information is correct
• Complete documentation for medical necessity for all patients Creating claims as well as fixing claims on the back end
• Held training sessions for new and existing employees

• Answer phones within 3 rings utilizing COCC scripting
• Accurately schedules appointments with multiple systems, coordinates special services and providers direction and instructions
• Determines appropriate Orthopedic appointment type and surgery
• Obtains and inputs patient demographic information, insurance ID numbers, group plans and co-pays with accuracy rate of 98%
• Completes end of day error reports maintaining accuracy rate of 98% Validates and obtains insurance coverage/benefits
• Collects results and reports from previous surgeries or referring physicians

• Register patients in courteous, efficient, and accurate manner
• Schedule patient appointments
• Collect co-payments from patients at the time of service
• Prepare charge tickets and reconcile charges and payments for over 30 providers Obtain accurate and complete registration information to ensure prompt billing and reimbursement
• Manage a booking ration for all child psychiatry doctors

• Scheduling of procedures, preadmission/admission data collection
• Ongoing maintenance of inpatient bed/ patient census activity
• Obtain precertification / verification of insurance and identified patient financial information provide financial counseling /customer service support