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
Registered Nurse (Utilization, Case Management) at Centers Plan for Healthy Living/ Elevance HealthRegistered Nurse (Utilization, Case Management) at Centers Plan for Healthy Living/ Elevance Health