Heather Allen

Led Medicare Advantage and TRICARE audits by designing scalable frameworks to validate claims data in line with reimbursement policies and methodologies. Developed and maintained an integrated audit database combining QNXT, TruCare, and EasyGroup, streamlining workflows, ROI modeling, and report automation. Used EasyGroup to validate DRG and OPPS payment logic and created custom views, stored procedures, and triggers to support configuration QA. Collaborated with cross-functional teams to resolve data discrepancies and align enterprise reporting. Regularly presented findings to internal stakeholders and the Defense Health Agency (DHA), contributing to standardized practices across TRICARE contractors. Also mentored analysts, authored training documentation, and advanced repeatable, scalable reporting processes.

Streamlined Medicare Advantage and TRICARE audit processes by developing automated reports, workflow documentation, and scalable SQL queries that improved claims accuracy and reduced manual effort. Led cross-functional initiatives with operations and compliance teams to support payment validation and configuration QA. Designed SSRS dashboards for reimbursement modeling, provider payment validation, and compliance reviews—driving enterprise adoption of automated tools and enhancing reporting accuracy across Health Plan Applications, Claims, and HIM.

Processed claims for MaineSense and other lines of business, specializing in identifying benefit and contract issues that impacted payment accuracy. Participated in building benefit and contract configuration logic during early phases of system development. Handled provider and internal escalation calls for the commercial line of business, resolving remittance discrepancies and payment issues.

Partnered with IT and Managed Care teams to troubleshoot and test configuration issues and mapping inconsistencies, while supporting configuration QA through early validation workflows and audit trails. Helped establish practices that evolved into the current audit database structure.

Utilized Microsoft InfoPath as a ticketing system for front-end users to report and escalate system issues, collaborating with the Benefit Administration team to identify and implement resolutions. Contributed to the transition of InfoPath to SharePoint as the team transitioned platforms.

Served as the first point of contact for providers under jointly administered accounts (JAA), resolving benefit, contract, and eligibility inquiries through both phone and written communication. Investigated claim discrepancies using the Facets platform and coordinated with internal and external Blue Cross Blue Shield partners to ensure resolution.

Mentored new representatives on system navigation, documentation standards, and customer service best practices, contributing to team readiness and service quality.

Supported administrative processes for life insurance claims involving portability and conversion options. Designed and implemented an automated mailing and imaging solution that eliminated the need for paper handling, significantly improving processing efficiency and ultimately phasing out manual workflows. Maintained contract files using Access and Merlin databases, managed vendor records, distributed checks and reports, and assisted with policy reconciliation.

Managed high-profile business accounts and negotiated payment plans to recover overdue balances, generating up to $120K in recovered revenue in a single month. Posted payments, reconciled accounts, and resolved escalated billing issues with a customer-first approach. Conducted collection audits and supported training and onboarding for new hires.