Hilda Collazo
Tarpon Springs,FL
Summary
Initiative-taking, problem solver and detail-oriented person with years of experience in the Health Plan business, operational and technology. Vast experience on claims adjudication, audit, and knowledge on all Medicare pricing methodologies. Experience on configuration of benefits and providers reimbursement agreements. Highly-motivated employee with desire to take on new challenges. Strong work ethic, adaptability, and exceptional interpersonal skills. Adept at working effectively unsupervised and quickly mastering new skills.
Overview
10
10
years of professional experience
Work History
Business Analyst/Product Owner/Supervisor Claims & Configuration
Advantasure
Southborough, MA
01.2010 - 01.2016
- Analyze, create, and design configuration requirements and specifications related to benefits, providers contracts and groups-built up
- Develop and maintain system configuration in accordance with Client’s business needs
- Research of complex claims adjudication and configuration problems providing viable solutions
- Audit of claims for correct processing of benefits, pricing and claims editing correct coding
- Design and implement solutions to support key Customer business objectives, including developing design requirements and technical specifications
- Train users in system application and configuration
- Serves as CMS Medicare Subject Matter Expert on benefits and Medicare reimbursement
- Review and assess CMS Transmittals, HPMS and others CMS communications for impact
- Review Product release documentation and coordinate deployment in Claims Platform environments
- Design and execute test plans, track defects, perform defect resolution to ensure business requirements and functional specifications are evaluated and fulfilled
- Create Detail Level Estimation, build, edit, and maintain Scrum team's backlog
- Write user stories and acceptance criteria and prioritization within the backlog
- Ensure that the team always has an adequate number of stories groomed and ready for work in the backlog
- Validate test results for completeness and requirements coverage before turning over to Clients
- Provide sprint Demo’s to Clients for the completed Epics
- Lead a Configuration and QA Team on new implementations and special projects
- Write performance reviews and goals for employees under my supervision.
- Managed projects and served as primary liaison between client and multiple internal groups to clarify goals and meet standards and deadlines.
- Collaborated with stakeholders across departments to define requirements for new projects.
- Delivered timely support by tracking issues and communicating resolutions to end users.
- Analyzed existing systems and processes to identify areas of improvement.
- Prepared documentation summarizing findings from stakeholder meetings and workshops.
- Identified gaps between current state and desired future state operations.
- Facilitated brainstorming sessions with cross-functional teams for problem solving activities.
- Designed test plans, scenarios, scripts, cases, and results matrices to validate system functionality.
- Gathered feedback from end users regarding usability issues related to applications or systems.
- Identified and analyzed user requirements, procedures and processes to develop optimization strategies.
- Recommended improvements to existing or proposed systems to enhance solution functionality.
- Drafted functional specifications documents outlining project scope, objectives and deliverables.
- Created detailed process flows and user stories to document system requirements and design solutions.
- Assisted in developing training materials for internal staff on new products or services.
- Collaborated with stakeholders to define features, integrations and partnerships.
- Reviewed existing policies and procedures against industry standards for compliance purposes.
Claims Supervisor/ Claims Manager
HMS of America
Tampa, FL
01.2007 - 01.2010
- Coordinated and assigned work for claim staff
- Audited processed claims for accuracy
- Researched, processed, and adjusted claims considered as priority by other departments
- Researched Medicare guidelines and regulations for proper adjudication of claims
- Interviewed and screened job applicants and assisted in hiring new applicants
- Trained internal and offshore employees
- Monitored and coached on all claim’s errors
- Interacted with internal departments and communicated with plan members and providers to resolve claim issues
- Interacted with the Compliance Officer on resolving CTM’s deficiencies
- Write performance reviews and goals for employees under my supervision.
Claims Examiner
Wakely & Associates
Largo, FL
01.2006 - 01.2007
- Analyzed claims to determine the extent of insurance carrier liability
- Audited processed claims for accuracy
- Interpreted contract benefits in accordance with specific claims processing guidelines
- Received, organized daily use of information regarding benefits, contracts coverage and policy decisions
- Coordinated daily workflow to coincide with check cycle days to meet all service guarantees
- Communicated with providers and policy holders as needed to adjudicate claims correctly
- Researched and reviewed medical records for policy rescission process.
Education
BA - Psychology
University of Puerto Rico
MA - Hispanic Literature
University of Puerto Rico
Skills
- Bilingual
- HIPAA EDI transactions
- Knowledge in medical and dental terminology
- Jira/Confluence
- Experience reviewing medical records
- Safe Agile Methodologies
- HIPAA Standard Codes (CPT, ICD-10, HCPCS, etc)
- Gap Analysis
- Business Process Improvement
- Internal Auditing
- Requirements Gathering
- Staff Management
- User Acceptance Testing
- Product Development
- Microsoft Office Suite
Leadership Experience
Lead and mentor Team members (QA’s & BA’s) on different applications throughout the system.
Communication Skills
Strong written and verbal communications skills, including the ability of analyzing CMS communications for writing systems requirements to be share with Clients and other stakeholders.
Timeline
Business Analyst/Product Owner/Supervisor Claims & Configuration
Advantasure
01.2010 - 01.2016
Claims Supervisor/ Claims Manager
HMS of America
01.2007 - 01.2010
Claims Examiner
Wakely & Associates
01.2006 - 01.2007
BA - Psychology
University of Puerto Rico
MA - Hispanic Literature
University of Puerto Rico
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