Summary
Overview
Work History
Education
Skills
Certification
Timeline
Generic

Jiwon Park

Northvale,NJ

Summary

Thorough Senior Analyst with over a 3-year background in healthcare claims review and analysis. Excellent planning, organizational and communication skills. Self-reliant to perform analysis and make recommendations. Talented in data modeling and client management. Self taught computer languages - JAVA, C, Python

Overview

14
14
years of professional experience
1
1
Certification

Work History

Claims Auditor

Centers Plan For Healthy Living
08.2023 - Current
  • Conducts monthly audits of CPHL claims processed internally or by Delegated Vendors utilizing CPHL guidelines, policies and procedures or any other regulatory requirements.
  • Compliance - Comprehensive analysis on contracts established with medical providers for insurance programs.
  • Reviews internal and Delegated Vendor production reports to ensure compliance with all regulatory requirements and CPHL policies.
  • Analyzes audit results to recommend system or procedural changes to increase claim accuracy and/or identify opportunities for workflow enhancements.
  • Maintains documentation of changes to claim processing guidelines and where appropriate, ensures policies and procedures are created or updated.
  • Communicates and follows up either orally or in writing with a variety of internal and external sources.

Quality Review and Audit Senior Analyst

Cigna - Express Scripts
07.2020 - 08.2023
  • Provide project-level analysis incorporating proposals, sequence diagrams, and scope matrixes.
  • Identifie and resolved problems through root cause analysis and research.
  • Process adjustments and adjudicate on claim transactions based on the health plan contractual agreements.
  • Adhere to internal processes/procedures to ensure claim auditing functions comply with company policies and procedure standards.
  • Investigate processed claims posing risks with fraud, waste, and abuse.
  • Analyze claims data and trends to forecast areas of potential program risk.
  • Train junior auditors on claims verification methods.

Certified Registered Dental Hygienist

Mountainview Dental Center
04.2017 - 07.2021

Floor Manager, Production Coordinator

Watchtower
02.2010 - 04.2017

Education

Associate of Science - Dental Hygiene

University of Manitoba
05.2010

Skills

  • Client Relationship Management
  • Investor Relations
  • Data Analysis
  • Spring Framework
  • Claims Audit
  • Quarterly Reviews
  • Investigative Approach
  • Compliance
  • Innovative

Certification

  • Licensed Dental Hygienist - College of Dental Hygienist of Ontario

Timeline

Claims Auditor

Centers Plan For Healthy Living
08.2023 - Current

Quality Review and Audit Senior Analyst

Cigna - Express Scripts
07.2020 - 08.2023

Certified Registered Dental Hygienist

Mountainview Dental Center
04.2017 - 07.2021

Floor Manager, Production Coordinator

Watchtower
02.2010 - 04.2017

Associate of Science - Dental Hygiene

University of Manitoba
Jiwon Park