Alexandre Pelizzuda Buhov

• Directly oversee onsite and offshore teams in managing enrollment and eligibility processes.
• Review, process, and maintain new member and re-enrollment applications, ensuring compliance with regulatory and Hoag timeliness guidelines.
• Ensure complete accuracy in data entry into internal systems, maintaining high data integrity and quality standards.
• Process enrollments, disenrollments, and cancellations within regulatory and Hoag timeliness guidelines, facilitating seamless member transitions.
• Provide enrollment reports and maintain audit records in the enrollment database, ensuring transparency and accountability in enrollment processes.
• Research and address various enrollment and eligibility questions and concerns, serving as a subject matter expert for internal staff and vendors.
  Stay updated on regulatory changes and ensure policies and procedures are current, proactively adapting processes to comply with evolving requirements.
• Educate managed care operations staff and vendors on respective changes, facilitating smooth implementation and compliance.
• Manage referrals and prior authorizations, ensuring timely and accurate processing to support patient care.
• Oversee the processing of approximately 2,600 referrals and 900 prior authorizations per month.
• Develop and maintain cross-departmental data dashboards and reports, providing insights and supporting organizational decision-making.
• Foster a collaborative and innovative team environment, highly regarded by senior leaders, peers, colleagues, and team members for assistance, especially with data analysis.

Achievements:

• Successfully rolled out the Enrollment Filer function within Epic, resulting in vendor expense savings, quicker turnaround times, and lower work volume for the enrollment team.
• Ensured timely and accurate loading of managed care health plan enrollment files, directly impacting timely access to care, authorizations, and claims payment.
• Adapted and resolved issues despite challenges with credentialing, network updates, and staff shortages, exceeding targets for the year.
• Enhanced data accuracy and improved cross-departmental communication, driving positive outcomes and operational efficiency.
• Completed key projects and achieved departmental goals, receiving positive feedback from team members and stakeholders.

• Developed dynamic dashboards for membership and capitation data centralization.
• Improved workflow, reduced errors, and increased productivity through various dashboard implementations.
• Assumed leadership of the E&E Department in the absence of a manager.
  Implemented a new audit process, reducing errors impacting IT EPIC Workqueues.
• Delegated workflow and priorities to team members.
• Maintained detailed and accurate records between multiple databases and programs.
• Provided technical support for troubleshooting analytics and reporting issues.
• Utilized data visualization techniques to present and explain complex data sets.
• Generated ad-hoc reports to evaluate specific business requirements.
• Analyzed data to identify root causes of problems and recommend corrective actions.

• Followed MSO guidelines and ensured compliance with regulatory procedures.
  Assisted in identifying and resolving eligibility and enrollment issues.
• Collaborated positively with internal and external partners.
• Maintained membership database, ensuring that all information was current and accurate.
• Identified issues and immediately stepped up to guarantee speedy and effective resolutions.
• Organized and detail-oriented with a strong work ethic.

• Entered provider details into the enrollment database.
• Coordinated credentialing data and analyzed reports for physician enrollment.

• Supervised and cross-trained staff activities. 
• Analyzed and processed various claim document types.

• Developed and managed soil and groundwater research projects. 
• Improved quality and productivity by streamlining systems and processes.

• Streamlined purchasing and inventory management processes. 
• Optimized the inventory system in collaboration with accounts payable.

• Developed forecasting tools and analyzed financial data. 
• Led monthly meetings with directors for financial analysis and recommendations.