Evelyn Silvestre
Raleigh,USA
Summary
Driven professional offering several years of experience in quality assurance, manually pricing medical claims, and managing inventory. Highly skilled at optimizing production workflows, leading toward achievement of benchmarks and maintaining qa standards. Skilled with a several-year track record of providing exceptional discretion, quality management and performance analysis services. Adept at training new hires and retraining employees and managing the accuracy of health medical claims.
Overview
20
20
years of professional experience
Work History
Quality Assurance Specialist
Coventry Healthcare Inc
05.2020 - 07.2021
- Review assigned claims on a daily basis in accordance to specific plan contracts
- Resolve questions regarding claims pricing and educate Claim Specialists about findings
- Manually tested claims to identify system errors
- Adhere to HIPAA regulations, policies, and procedures
- Work independently and meet all deadlines with 98.5% or above quality
- Worked on additional projects and duties as assigned during/after Aetna CVS Healthcare acquisition
- Collaborated to prioritize system recommendations for improvement
Quality Analyst
Aetna CVS Healthcare
06.2011 - 05.2020
- Resolve claim pricing situations following policies and procedures
- Independently able to meet deadlines, production, quality, and performance standards
- Identify client contracts pricing inefficiencies
- Document and communicate the findings and results from claim testing
Claim Benefit Specialist/Backup Lead
Aetna CVS Healthcare
02.2001 - 06.2011
- Accurately resolve pending claims following state and federal regulations and specific health plan criteria
- Meeting productivity and accuracy standards
- Manually priced Workers Comp Claims based on U&C and Fee Schedule State laws
- Prepare Inventory Report for upper management, regularly assist with releasing Pend Reports for clients, and acquire additional projects
- Monitored team assigned work to meet productivity and deadlines
- Counted inventory to keep the system accurate and current
- Coach colleagues, train new hires and perform internal audits to ensure accuracy of pricing
Education
Sterile Processing Technician -
Ashworth College
06.2024
Healthcare Management Certificate - undefined
Ashworth College
12.2012
Associates Degree - General Studies
Glendale Community College
Glendale, AZ05.2012
Skills
- Microsoft Office
- Coventry Provider Database (CPD)
- Provider Contract Manager (PCM)
- Managed Care Pricing System (MCPS)
- Bilingual in English and Spanish
- Lead duties
- Multiple assignments
- Accuracy
- Performance monitoring
- Application audits
- Customer service
- Team collaboration
- Quality improvements
- Sound decision-making skills
- Analytical thinking
- Verbal and written communication
- Manual testing
- Personnel management
- Problem-solving skills
- Testing processes
- Application testing
Timeline
Quality Assurance Specialist
Coventry Healthcare Inc
05.2020 - 07.2021
Quality Analyst
Aetna CVS Healthcare
06.2011 - 05.2020
Claim Benefit Specialist/Backup Lead
Aetna CVS Healthcare
02.2001 - 06.2011
Healthcare Management Certificate - undefined
Ashworth College
Associates Degree - General Studies
Glendale Community College
Sterile Processing Technician -
Ashworth College
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