Amanda Nicholls
Longs
Summary
Experienced in front-facing account reconciliation, ensuring compliance with contracts and regulatory requirements for UnitedHealthcare. Proficient in analyzing large data claims submissions to address fraud, waste, error, and abuse. Skilled in managing mass tort liens and antitrust claims for National Recoveries, ensuring legal compliance. Successfully implemented web-based tools to enhance staff end-user experience. Collaborated with offshore teams to automate business processes for the PICTS system. Proven ability to train teams to meet KPIs and metrics goals.
Overview
21
21
years of professional experience
1
1
Certification
Work History
National Recoveries Consultant-Legal Compliance & Regulatory Affairs
Optum
01.2022 - Current
- Publish notice of Pharmaceutical Settlement communications received in OneConnect, ePharmacy News, EnableRx; review settlement terms and filing requirements and prepare summary of case
- Request Data from all client data sources, providing case summary, parameters, and standard data elements
- Prep communications and client impact lists for National and Strategic Account Executives for self-funded plans including the option to file claims for their clients
- Prepare claims for UHC and ASO clients
- Upon approval, file claims by the deadline
- Upon receipt of payments, break out data by client, prepare financial statement, update reporting based on contractual agreements for financial arrangements
- Obtain notice of Tort Action (from outside counsel or internal counsel) received, review case, terms, and participation requirements
- Receive communication from Outside Counsel/Lien Administrator with Plaintiff List or list of requested Policy Documents; prepare member data match with over15 integrated UHC platforms for all lines of business
- For Outside Counsel, pull data analytics into standard templates for Lien Administrator, pull and narrow data according to terms for Lien Resolution Program negotiation to occur
- Review and respond to audit based on post-pay medical claim analysis results provided to Lien Administrator
- Also manage, track, and verify liens from beginning to end
- Prepare financial allocation when settlement proceeds are received; update financial statement and reporting, including monthly paid projections
- For states that preclude subrogation, obtain policy language to prove subrogation rights
- Work closely with Optum & United Health Group Legal and Medical Directors and vendors, providing support in data collection, analysis, matching for various ongoing litigation efforts and complex projects
- Prepare and send quarterly reporting to client groups within UHC organization
- Project recoveries using past and present financials yielding $66M+ in recoveries in 2024
Team Lead -COPS Post Pay Professional
Optum
01.2021 - 01.2022
- Aid with creating and maintaining member scorecards; compiling metrics assisting with performance management; coaching and training and development
- Collaborating directly with automation team in Ireland for robot mapping, testing and implementation project set for 2022 to improve production from case inventory volume using timetable tests to determine Full time employee hours requirements
- Utilized reporting tools for generating effective reporting for Leadership; facilitate changing work directives and managing escalations/inventory
- Prepare and facilitate ongoing training opportunities for team members both on and offshore for the United States, The Philippines and India
- Perform daily audits on work completed by the new members to ensure understanding of policies and procedures of the department
- Reduced case inventory from 3,000 cases to 320 cases from June to August of 2022
- Managed daily work inventories for team workflows and dashboards
Fraud SIU Resolution Analyst
Optum
01.2016 - 01.2021
- Collaborate with investigators/ clinicians and provider contacts, along with legal counsel to evaluate the potential cost savings for payment integrity healthcare paid claims and cases related to fraud and waste & error cases for UnitedHealthcare products
- Analyze and adjudicate errant paid accounts utilizing multiple data source reporting and contracts to result in cost savings referred to OPTUM SIU, applying multiple payment methodologies to healthcare products including Community and State, Employer and Individual and Medicare and Retirement lines of business
- Calculate and extrapolate statistically random sampled claims from RATSTATS that are projected onto a universe consistent with CMS guidelines; address appeals that require recalculating findings from updated medical record reviews
- Draft letters to providers regarding findings from clinical reviews of medical records and calculations from sampling analysis; Submit compliance reporting to both the health plans and state regulators as necessary, working with both OPTUM client services and Government and case affairs adhering to Lookback and statute of limitations guidelines
- Assisting in MACRO testing for a key in-house tool to improve processes through automation to decreases turn-around time for metric based Key performance indicators
Regional Account Manager
Ingenix/Optum
01.2004 - 01.2016
- Performed on-site audits in a front-facing role to multiple providers recovering errant paid claims based on provider contracting and billing; Utilized provider systems and reporting tools involving multiple payment methodologies for over 1,000 payer clients
- Complied monthly paid projections for cost savings budgets; Recovered over $11 Million in savings on average per year
- Collaborated directly with Revenue cycle directors and key contacts in managed care, contract management and billing managers to resolve trends in overpayment patterns with breakdown analysis reporting for client payers
- Audited unidentified payments from lock box for clients and provided non-cash adjustment assistance for contractual and charity adjustment errors
- Reviewed facility and professional claim forms including pricing of CPT and HCPCS codes from ICD-10 for errors due to changes in billing, improper discount, duplicate billing, interim billing, upcoding and unbundling
- Identified eligibility errors and applied coordination of benefits and subrogation rules to claims that qualified
- Claims processing/billing/ editing software knowledge
- Collaborated with provider regarding Skilled Nursing facility and patient transfer claim overlap along with Crime Victims service payment allocation from the state
- Implemented the Business Intelligence (BI) access training to provider contacts for Direct Connect OPTUM application for Akron Children’s Hospital end users
- Mapped testing logic for (BI) for increased confidence level outcomes
- Provided on-site training to new hires for ramp up period, which included systems training and processes for identifying and verifying trends and errors from billing and reporting breakdown; Conducted interviews for potential new hires
- Partnered with UnitedHealthcare Provider Advocate in facilitating training for directors and cash posting staff regarding offsets and provider-level adjustments for 835 electronic payment PLB process
Education
Bachelor of Arts - Communications
Ashland University
Skills
- Reimbursement methodologies
- Patient Accounting Systems
- Pricing Tools
- Analytical Solutions
- Account Reconciliation
- Claim Extrapolation
- Analytics Reporting
- Revenue Cycle Process
- Contract Analysis
- Claim/Billing Analysis
- Organizational Management
- Regulatory Compliance
- Mass Tort
- Antitrust Claims filing
- Payment Integrity
- Post Pay
- Microsoft Office Suite
- Tableau
- ISET
- PICTS
- SAS EG
- EPIC
- DWaaS
- Doc360
- Devlin
- Webstrat
- DocDNA
- IBAAG
- RATSTATS 2007
- SOARIAN
- Quadax Expeditor
- Subropoint
- Direct Connect
- ODAR
- ORMS
- ACIS
- IDRS
- MITS
- ICUE
- Snowflake
- Optum Consolidated Service
Certification
National Health Care Anti-Fraud Association (NHCAA), 9+ compliance hours for yearly requirements
Timeline
National Recoveries Consultant-Legal Compliance & Regulatory Affairs
Optum
01.2022 - Current
Team Lead -COPS Post Pay Professional
Optum
01.2021 - 01.2022
Fraud SIU Resolution Analyst
Optum
01.2016 - 01.2021
Regional Account Manager
Ingenix/Optum
01.2004 - 01.2016
Bachelor of Arts - Communications
Ashland University