Gabriel Payan

Role Summary
Led cross-functional teams and partnered with vendors to implement new claims intake application and update existing application operational improvements across multiple markets. Focused on enhancing data accuracy, compliance, and efficiency through system onboarding, reconciliation controls, and front-end editing solutions, including Claim Manager and Stored Procedures, by implementing business rules and validating SQL logic for measurable process improvements and savings.

Key Accomplishments

• Directed onboarding of Smart Trader (Edifecs) and Availity across 18 markets, improving claim intake accuracy, reducing SNIP rejects by 22.8%, and generating over $115M in billed charge savings
• Led cross-functional teams to implement operational improvements and new applications, achieving 90% on-time project delivery.
• Reconciled inbound claims data to ensure accurate processing into QNXT (paying system) and established reconciliation controls with Audit, improving accuracy.
• Developed ROI analyses for Smart Trader and front-end editing solutions, preventing downstream encounter rejects.
• Educated business partners and providers on state-specific editing rules, reducing errors and improving compliance.
• Supported front-end editing tools (Claim Manager and Stored Procedures) by implementing business rules and validating SQL logic, driving measurable process improvements and saving.

Role Summary
In this role, I collaborated with cross-functional teams, health plans, and external vendors to resolve encounter rejections, recover revenue leakage, and enhance QNXT application functionality. I self-managed multiple projects simultaneously, facilitated stakeholder and vendor meetings, and combined short-term SQL solutions with scalable automation and vendor-driven enhancements to improve data accuracy, compliance, and operational efficiency.

Key Accomplishments

• Partnered with health plans and cross-functional teams to resolve encounter rejects, recovering millions in potential revenue leakage and improving compliance across multiple markets/states.
• Collaborated with QNXT(paying system) vendor (Cognizant/Trizetto) to enhance system functionality—integrating Taxonomy, SOI, and Final DRG—which improved claims transparency and reduced adjustment errors and rework by 20%.
• Implemented enhancement for Advanced Duplicate Editing by translating market needs into technical/business rules, reducing duplicate claim rejects up to 80% and improving processing accuracy.
• Standardized NDC validation across 7 states, migrating processes to Custom Editing, enabling real-time adjudication and reducing manual intervention on average by 5 hours/week per claim analyst.
• Designed and executed SQL-based pre-check queries and BDUs that proactively stopped high-impact leakage, preventing recurring monthly losses.
• Facilitated cross-functional and vendor meetings to drive alignment, ensure timely delivery, and manage competing priorities across multiple initiatives.
• Measured project impact through pre- and post-ROI analysis, demonstrating millions in savings and measurable improvements in operational efficiency.

Role Summary
Supported reporting needs for a new line of business by developing, enhancing, and streamlining reports to improve decision-making and operational efficiency. Partnered with business stakeholders to assess reporting requirements, eliminate outdated reports, and implement enhancements to ensure accuracy, relevance, and value.

Key Accomplishments

• Created and maintained reports to support a new line of business, ensuring stakeholders had accurate and timely insights.
• Partnered with business users to review existing reporting inventory, eliminating outdated or redundant reports to reduce clutter and improve efficiency.
• Enhanced existing reports by updating calculations, equations, and data sources, resulting in more accurate and actionable outputs.
• Collaborated with stakeholders to gather requirements, validate reporting logic, and align outputs to evolving business needs.
• Improved reporting processes by standardizing formats and ensuring consistency across teams.

Role Summary
Configured and supported company applications (QNXT) to meet evolving business needs while partnering with Health Plans and Claims inventory teams to eliminate unnecessary pends. Leveraged automation tools including AutoQ, Bots, Stored Procedures, and Custom Edits to streamline claims processing, reduce manual effort, and recover significant revenue. Provided end-to-end support for configuration design, testing, and upgrades while developing SQL solutions for reporting and business requests.

Key Accomplishments

• Developed and executed configuration requirement documents, ensuring accurate implementation and on-time delivery of business needs.
• Partnered with Health Plans and Claims inventory teams to identify root causes of pended claims, eliminating unnecessary pends and reducing departmental inventory by 70% on average and up to 98% in some plans.
• Automated key processes using AutoQ, Bots, Stored Procedures, and Custom Edits, saving several hours of manual work per week, increasing efficiency and saving in the millions.
• Resolved configuration issues promptly to improve claims throughput, reducing rework and preventing potential revenue leakage.
• Supported system analysis, testing, and patch releases while recommending process improvements that enhanced system performance and reduced recurring issues.
• Created and maintained SQL queries for reporting and BDU requests, delivering short-term fixes and scalable long-term automation.

Role Summary
Managed provider configuration across 18 markets, ensuring accuracy in demographics, contract alignment, and service/pay-to affiliations. Partnered with health plans and internal teams to resolve provider-related claim pends, support enrollment and credentialing, and improve provider data quality through audits and process enhancements.

Key Accomplishments

• Oversaw provider configuration, maintaining accurate demographics, contract alignments, and service/pay-to affiliations.
• Conducted audits of provider data to identify trends, resolve issues, and implement process improvements.
• Managed provider enrollment and credentialing, keeping provider directories accurate and compliant.
• Resolved claim pends related to provider setup issues, supporting health plan staff directly.
• Validated provider NPI, licenses, and other identifiers using internal systems and external sources.
• Logged and tracked provider change requests (PCRs) in Remedy, ensuring timely follow-up and resolution.

Role Summary
Processed paper and electronic claims, including complex HCFA 1500, UB04/UB92 forms, ensuring accuracy, compliance, and adherence to company protocols. Analyzed claims that could not be auto-adjudicated, applying medical necessity guidelines, verifying eligibility, and identifying discrepancies to support accurate and timely claim adjudication.

Key Accomplishments

• Processed and reviewed medical claims to determine benefit eligibility and accuracy for insurance reimbursement.
• Handled complex HCFA 1500, UB04/UB92 forms, ensuring compliance with company and regulatory standards.
• Analyzed claims that could not be auto-adjudicated, applying medical necessity guidelines and cost containment measures.
• Verified patient eligibility, identified discrepancies, and resolved issues to facilitate accurate claim payment.
• Supported efficient claims workflow by maintaining adherence to protocols and quality standards.