BRIAN KELSEY
Business Analyst
Riverview,FL
Summary
Business Professional with over a decade of progressive experience in healthcare operations, specializing in: Provider Data Management, Utilization Management, Member Liaison, and Pharmacy . Proven track record in optimizing workflows, ensuring data integrity, and fostering cross-functional collaboration to enhance operational efficiency.
Overview
19
19
years of professional experience
Work History
Business Analyst II
Centene Corporation (SSHP)
10.2022 - Current
- Collaborate with various departments to resolve workflow challenges related to Provider Data Management.
- Conduct audits and data analyses to support business needs, ensuring data integrity and network adequacy.
- Analyze assigned projects and ad hoc requests to develop and recommend effective solutions.
- Customize SQL queries from templates to extract data from Portico and Amisys database, to support auditing, analysis, validation, and provider record updates.
- Utilize Excel (PivotTables, VLOOKUP, IF statements, conditional formatting, and filtering) to organize, analyze, and maintain datasets efficiently, for accurate reporting and data driven decision making.
PDM Specialist I & II
Centene Corporation (SSHP)
02.2019 - 10.2022
- Managed multiple queues within PDM including - Intake (loading provider rosters and contracts), Triage (Assigning cases to enrollment team), and Enrollment (Entering provider data into Portico per established guidelines).
- Oversaw PDM inbox, addressing inquiries from Prior Authorization and Claims teams related to PDM loading processes and submission protocols.
- Trained call center staff on intake procedures for special projects.
- Provided training to the contracting team on intake processes to support system integration.
Program Coordinator I
Centene Corporation (SSHP)
08.2016 - 02.2019
- Researched claim inquiries related to authorization requirements.
- Audited check run reports across multiple lines of business to ensure accuracy.
- Reviewed appeal requests for claims denied due to missing or invalid authorizations.
- Identified negative trends and process improvements to enhance workflow efficiency.
- Distributed authorization error reports to staff and provided guidance on correcting errors.
- Processed authorizations for services downgraded in level of care for payment integrity team.
- Submitted system tickets to correct authorization errors on the backend.
- Submitted configuration tickets to update web portal and auth guidelines.
Referral Specialist I & II
Centene Corporation (SSHP)
04.2014 - 08.2016
- Initiated authorization requests for outpatient and inpatient medical services through phone, fax, and online submissions.
- Managed incoming calls to provide status updates on existing authorizations and guidance on initiating new requests.
- Communicated policies, submission protocols, departmental guidelines, and turnaround times to providers and staff.
Client Lisaon
United HealthCare
09.2013 - 04.2014
- Served as a liaison for members, providers, brokers, and employers.
- Responded to inquiries regarding health plan policies, procedures, and coverage details.
- Verified member benefits and eligibility.
- Assisted customers in understanding copays, eob's, deductibles, and coverage gaps.
- Researched claim inquiries and submitted discrepancies for reprocessing.
- Explained plan exclusions, healthcare regulations, and company mandates.
- Reviewed disputes, appeals, and pharmacy-related tasks to ensure accurate resolution.
Member Services
Aetna Pharmacy
05.2007 - 12.2012
- Processed prescription requests for Aetna's mail-order pharmacy service.
- Responded to inquiries regarding billing, deductibles, and copay structures.
- Verified member benefits and eligibility information.
- Registered new members and updated account information.
- Managed reship and return requests for undelivered items.
- Processed claim overrides for denials at the retail pharmacy level.
Education
Some College (No Degree) - Science
Broward College (BCC)
Ft. Lauderdale, FLSkills
Technical:
- Excel
- SQL
- Business Analytics
- Micro-Strategy
- Toad
- Teradata
Core Competencies:
- Provider Data Management
- Authorization Management
- Claims Inquiry Research
- Appeals Review Support
Timeline
Business Analyst II
Centene Corporation (SSHP)
10.2022 - Current
PDM Specialist I & II
Centene Corporation (SSHP)
02.2019 - 10.2022
Program Coordinator I
Centene Corporation (SSHP)
08.2016 - 02.2019
Referral Specialist I & II
Centene Corporation (SSHP)
04.2014 - 08.2016
Client Lisaon
United HealthCare
09.2013 - 04.2014
Member Services
Aetna Pharmacy
05.2007 - 12.2012
Some College (No Degree) - Science
Broward College (BCC)