Carla McIntosh
Coral Springs,FL
Summary
As a Senior Quality Consultant at Aetna, a CVS Health Company, I apply my data analysis and process improvement skills to ensure the quality and accuracy of Medicare Part D claims reviews and audits. I have over six years of experience in this role, and I hold the Registered Health Information Technician (RHIT) certification from AHIMA.
I collaborate with internal and external stakeholders, such as Pharmacy Benefit Manager (PBM) staff, network providers, and members, to facilitate effective communication and resolution of issues. I also contribute to initiative planning, relationship management, and satisfaction for assigned projects that impact the review of Medicare Part D claims. My mission is to deliver reliable and efficient solutions that enhance the quality of care and service for our customers.
Overview
17
17
years of professional experience
1
1
Certificate
Work History
Senior Quality Consultant
Aetna, A CVS Health Company
09.2017 - 08.2023
- A key player in creating a solid process and work instruction for the clinical claim quality review of BvsD drugs which involves data analysis of the member's claim and medical history and externally contacting the member's pharmacy and prescriber for additional information so that a BvsD determination can be made which involves entering of coverage determinations for coverage.
- Involved in initiative planning, ongoing relationship management and satisfaction for assigned initiatives that impact the review of Medicare Part D claims.
- Create and oversee daily Part D claims reviews and monthly Part D Claims audits, including reporting.
- Collaborates with Pharmacy Benefit Manager (PBM) staff, team members and internal matrix partners as required in support of initiatives.
- Accountable for transferring knowledge, best practices (external and internal), methodology and tools to team members both internal and external.
- Participates as a team member, may be responsible for concurrent initiatives or act as team lead for less complex projects based on resource requirements.
- Evaluated situations and delivered targeted solutions using various tools and resources.
- Established and maintained relationships with key stakeholders for growth opportunities and successful partnerships.
- Implemented process improvement to shape organizational culture, optimize procedures for higher efficiency and help company evolve and grow.
Network Consultant
Aetna, A CVS Health Company
08.2015 - 08.2017
- Directly involved with the Long Term Care Migration from Independent Living Systems in October 2015, and a key player in the migration's success from a provider perspective
- Performed UAT system testing to prepare for a successful migration from Coventry Healthcare of FL to Aetna Better Health of FL on 2/27/17
- Assisted in major data reconciliation projects
- A valuable resource to internal counterparts in the Medicaid department which also includes Healthy Kids and Long Term Care lines of business
- Acted as Team Leads which involved assisting with questions from internal departmental counterparts, maintain and monitoring the Provider Relation's phone queue, handling complex provider issues, etc
- Created and/or managed cooperative working relationships with providers through correspondence and telephone contact
- Educated providers which involved assessing needs and designing and developing training and educational materials
- Coordinated distribution of educational materials
- Conducted ongoing analysis and refinement of provider networks to assure appropriate network composition and system maintenance
- Conducted and managed ongoing audit of provider information
- Worked with management to draft, clarify and recommend changes to policies which impacted Network Management Provider Relations, and Care Management
- Handled complex claim and contract issues experienced by providers
Enrollment Specialist II
Change Healthcare
06.2014 - 04.2015
- Managed the completion and submission of provider enrollment applications for EDI, ERA, and EFT submissions to commercial and government payers
- Provided telephone assistance to providers when completing provider required enrollments through payer online portals
- Served as a liaison to insurance (payers) and other service providers
- Performed tracking and follow-up to ensure that enrollment applications submitted to payers are processing in a timely manner
- Understand specific application requirements for each payer including-pre-requisites, forms required, form completion requirements, supporting documentation and regulations
- Maintained documentation and reporting regarding provider enrollments in process
- Retained records related to completed provider enrollments
- Worked closely with the Implementation Analyst and enrollment representative on behalf of the provider to obtain signatures, locate required documentation, etc.
Provider Data Coordinator
Centene Corporation
02.2013 - 04.2014
- Perform day to day functions from inbound requests and maintain provider database
- Audit analyses on completed requests and monitor compliance status of submitted requests
- Analyze inbound request to determine accuracy and route request to provider changes or other cross functional teams
- Maintain provider data management systems for accuracy
- Handle and resolve provider data issues, such as mass change updates, limited reconciliations and direct submissions of urgent requests
- Coordinate provider data between the health plan database and various internal databases
- Participate in reconciliation and provider data projects
- Review, investigate and resolve inquiries regarding loaded providers that may have issues reported from internal and external customers
- Initiate and process provider add, change and termination forms
- Track, update and audit provider information in database
Senior Customer Service Representative
Aetna, A CVS Health Company
06.2006 - 12.2012
- Resolved more than 400-600 calls per week depending on the volume of calls while maintaining all performance metrics which includes speed, accuracy and volume
- Participated in multiple special projects which included assisting in a queue for the more challenging calls, a queue that mentored other internal Aetna Pharmacy Help Desk reps on their calls, and a
- Mentor in the Pompano Coaching Program which was designed to ensure success beyond the training environment
- Selected by management to represent the Aetna Pharmacy Management Department as the SME (Subject Matter Expert) in teleconference business meetings
- Cross trained to perform prior authorization audits for the Learning and Performance Department, processing of member pharmaceutical claims in APM Claim, and answering/resolving inbound calls from members of Aetna Rx Home Delivery
- An Aetna Pharmacy Help Desk Representative for pharmacies, members, medical Providers and third party representatives that would make an inbound call for pharmacy benefit verification, claim inquiries, and any other pharmacy related issue/inquiry
- Assisted with questions in reference to over-payment invoices received by members, questions in reference to drug pricing, claim reimbursements, contract inquires, coordination of benefit issues, and handled all Medicare Part D issues and benefit questions.
Education
Associate of Applied Science - Health Information Technology
DeVry University (Online)
Downers Grove, IL10.2017
Skills
- Quality Assurance
- Cause and Effect Analysis
- User Acceptance Testing (UAT)
- Data Analysis
- Employee Supervision
- Knowledge of Quality Systems
- Quality Control
- AS400 & QNXT Experience
Certification
- AHIMA certified RHIT - Registered Health Information Technician credential ID 222279 effective October 2022-September 2024
Timeline
Senior Quality Consultant
Aetna, A CVS Health Company
09.2017 - 08.2023
Network Consultant
Aetna, A CVS Health Company
08.2015 - 08.2017
Enrollment Specialist II
Change Healthcare
06.2014 - 04.2015
Provider Data Coordinator
Centene Corporation
02.2013 - 04.2014
Senior Customer Service Representative
Aetna, A CVS Health Company
06.2006 - 12.2012
Associate of Applied Science - Health Information Technology
DeVry University (Online)
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