DiVonne Patterson

Manage over 5,000 members enrolled under Small Business Health Options Program (SHOP) for the District of Columbia (DCHBX), and Maryland (MHBE) Benefit Exchanges, including enrollments, monthly reconciliations, escalations, and stakeholder meetings. Participates in National and Regional Project Teams as a tester for the project. Compiles, calculates, prepares and distributes Ad-Hoc and standardized reports. Assists with data interpretation by organizing and editing reports and presentations for stakeholders to enable and influence decision making for SHOP. Works closely with the development team to assist in business decisions Supports data-informed decisions under the guidance of more senior employees by working with clients to identify and clarify key business needs; assisted in the RFI process for MHBE’s onboarding, ensuring outcomes and process measures; translating business requirements; informing data/information needs and data collection methods; measuring the impact of business decisions on clients, customers, and/or members; working with clients and staff to identify opportunities and methods to improve efficiencies with analysis; supporting end-users; and documenting processes and deliverables.

Individual contributor for MAS Region Annual HHS/CMS Risk Adjustment Data Validation (RADV) audit. Interpret and Prepare data for analytical efforts by integrating and consolidating data; ensuring data quality and accuracy; profiling data inaccuracies, also recommending process improvements or system changes to enhance overall quality; by gathering data and information on targeted variables in an established systematic fashion by validating data sources; querying, merging, and extracting data across sources.

As a Business Analyst, provided technical expertise related to Membership Administration operational processes which includes consulting with staff, managers, and management personnel to enhance, and maintain organizational standards and reports. Participates on National and Regional Project Teams as a tester for the project. Compiles, calculates, prepares and distributes Ad-Hoc and standardized reports for the department. Develops operational policies and procedures in conjunction with management. Works with groups, vendors and other departments on national and regional levels as needed to achieve work flow. Provides analysis of complex and problem areas through identification of root causes, interim actions, and long term solutions. Utilize software applications to develop management reports, maintain and update system dictionaries within the TMS system. Coordinate system downloads, that is required for electronic data. Review and provide input into RFP’s. Primary focus on The Affordable Care Act (ACA) On Exchange (HIX) Individual and Shop for DC, MD AND VA) products to ensure all enrollments have been processed in accordance with Federal guidelines, under The Department of Health and Human Services/ CMS.

SME Contractor for Kaiser Permanente as a Business Analyst in the Membership Administration Department, responsible for processing applications for new membership to enroll in individual and family plans (KPIF) Off HIX, under The Affordable Care Act. Process new and existing enrollments for Small Groups, Maryland Medicaid, Virginia Medicaid; Verifies accuracy of information on source documents and applications; enters demographic and rate data information into system database for small group contracts, family and individual products. Enters revisions to group and individual products as outlined in the contract and ensures the readiness of billing batches before monthly billing cycles begins, dues billing, prepares batching of documents for Macess EXP. Performs monthly terminations of groups based upon request received; group transfers, address updates, maintains and updates Excel spreadsheets to query large data sets. Responsible for uploading applications from SMU and E-Health systems, process applications from the Health Insurance Marketplace, create and maintain monthly premium due letters to members, create and maintain excel spreadsheets for all incoming members looking to join the Health Plan. Process future terminations for group plans, create new membership Welcome letters, SEP and status of enrollment letters and other duties as assigned.

Contracted Consultant specializing in Healthcare Regulations/Guidelines/ and Procedures. Selected (RFP) and presented at Oral Presentations as key personnel for The Centers for Medicare and Medicaid Services (CMS) Jurisdiction J MAC as the Claims Processing Manager for a Multi-Million Dollar contract for I-Gate Government Solutions. Key presenter on Claim’s processing/payment procedures, Appeals for the CMS Panel Review Board. I advised on changing healthcare reform under the Affordable Care Act, researched new or impending regulations, also advised stakeholders on various changing processing procedures and how CMS responds to the Beneficiary. Additional duties include research new Federal contracts for new business using various tools, (GovWin, FBO, SAM, etc.) Make points of contact with other businesses to partner with, analyze market trends, and recommend business solutions.

Contracted Quality Assurance Monitor/ Team Lead for the Centers for Medicare and Medicaid Services (CMS) Remote and Direct Monitoring PCC Project. Responsibilities included monitoring and providing customer response support to 40 Provider Contact Centers for Medicare Part A, B Title XVIII, A/B MACs, DME, DMEMACs. Additional duties included analyzing/researching content of the call; identifying trends in customer responses, collecting and transcribing inquiries about Claims, Benefits, Durable Medical Equipment, Provider enrollment or Policies/Procedures/Regulations. Additionally monitored staffing contractor’s queue (IVR) to monitor the calls by selecting a category/sub-category the QM provided a synopsis of the call to ensure the call was recorded and transcribed correctly for the Remote Monitoring piece of the project. Monitored provider telephone inquiries handled by Medicare Provider Contact Centers (PCCs). Maintained call Monitoring Records; collected, direct and remotely monitored data in questionnaire and scorecard formats, linked the data collected to the voice records, including customer service representative (CSR) callbacks. Tracked data reports for error, inquiry type, and assigned value to the information collected from the monitoring transactions, to analyze data to identify trends and correlations based on variable data sets.
Performed quality reviews for accuracy of information provided by CSRs through standardization activities including selection of appropriate call types and customer satisfaction evaluations, step by step URL directions to various contracted websites but not limited to the CMS website to be verified and scored. Provided recommendations to improve quality or service and evaluation/scoring criteria. Evaluated and analyzed performance standards, conveying the results and recommending necessary actions to obtain maximum results. I provided feedback on how to improve internal processes, customer service skills and CSR training at the PCCs. Prepared/compiled monthly deliverable reporting and also trained all CMS PCC Project Quality Assurance Monitors on standard operating procedures, transcriptions, and taxonomy vocabulary for both Direct and Remote Monitoring selections. Also, assisted/provided Project Manager with healthcare terminology/ questions for RFI’s, RFP’s, and other duties as assigned.

As a Claims Adjudication Specialist, I was responsible for adjudicating 150 Medicare Supplemental, Medicaid, Commercial, EDI transmissions, Employee Assistance Program (EAP), HMO and PPO claims per day by applying claims payment criteria/laws as well as medical terminology (ICD-9, CPT) issued by the American Medical Association to investigate and resolve discrepancies on pended and incorrectly processed claims. I also adjusted and edited inconsistencies in information by applying APS policy and procedures to client specific claims payment criteria on all overturned appeals/complaints and identified, researched pending claims requiring referrals to support areas for evaluation or correction of data. I tracked claims to ensure that claims are returned and resolved within claims processing parameters achieving stringent quantitative and qualitative productivity goals. Served as the Team Lead for the claims customer service department and as the Liaison between the call center staff and program supervisor. Responsible for the management of 12 claims customer service representatives including the development implementation of all training manuals for all requirements related to policies and procedures as required by statutory requirements. Responsibilities also included verification of benefits, authorizations, and claim status and payment information. Processed claims for payment and adjusted claims that had been over/under paid incorrectly, also calculated reimbursement for providers/ members for services rendered; initiated requests for stop pay/reissue checks and compiled/created/completed request for refunds/recoveries. Additionally, responsible for deliverables and communications with the Recovery/Finance Department with retracting/recovering monies owed to APS. Handled all escalated issues, voicemails for program supervisor.

Responsible for the program policy procedure development and contracting billing and provider licensure staff training. Created and disseminated training documentation and outreach and communication guidance. Responsive to high volume providers assistance calls pertaining to incorrect claim payments, benefits, contractual issues, billing questions and/or fee schedules. Performed silent monitoring techniques to ensure procedural uniformity regarding information provided to network/out of network providers. Processed providers’ requests for additional claim payments due to incorrect fee assessment, compile/create/complete request for refunds/recoveries. Conducted research, developed materials as requested by the Manager of Provider Relations and compiled deliverables which contained payment details from overpaid provider accounts. Provided Network/Out of Network Negotiations to provider, serving as provider liaison to ensure all provider issues had been resolved. I worked closely with the provider relations manager reviewing participation contracts/fee schedules/deliverables.