Hi, I’m
JOHN HUMBER
Alpine,CA
Summary
Experienced Health Care Analyst and Project Manager with a stellar demonstrated 15+ year history of working in the hospital, health insurance and eye care industries. Skilled in all aspects of the health care revenue cycle, claims management process, membership data files, data mining for claims, payment integrity, insurance billing, claims analytics and follow-up.
Well versed in Medicare, Medicaid, DSNP, commercial, Blue Cross, VA, and US military government health insurance programs. Well-trained in COB, eligibility, and authorization procedures.
Exceptional communication skills including presentations to audiences of all levels. Experienced trainer, SME, and team lead. Exceptional remote worker with great time management, organizational and multi-tasking skills. Accomplished Sales management leader of teams.
Overview
16
years of professional experience
Work History
Cotiviti, Inc.
Senior Payment Accuracy Specialist/Business Analyst
01.2022 - Current
Job overview
- Utilize healthcare experience to perform audit recovery procedures for health plan clients
- Identify and validate incorrect medical claim payments, create ideations, concepts, and cases for Commercial, Medicaid/Medicare and Military healthcare insurance clients
- Exceed yearly goal of over 60 concepts/ideations and recoupment of over $1,700,000
- Identify and define issues, develop criteria logic, review, and analyze contracts and Health Plan reimbursement regulations
- Create plans and strategize for ROI of concepts and adherence of all KPI's and other metrics for insurance health plans
- Develop standard operation procedures and train other auditors on new concepts as a SME
- Update and develop new and current audit recovery reports
- Develop and run custom claims queries for new concepts
- Create white papers for health plan clients using proven methodology and claims rule logic
- Lead and helped develop new equity, diversity, and inclusion programs for the company.
EyeMed Vision Care
Strategic/National Client Support Operations Project Manager
02.2020 - 01.2022
Job overview
- Lead the post-implementation operational support of operations issue resolution
- Analyze performance analysis, report, and drive for resolution of membership, billing, and claims processing trends with the goal of improving effectiveness as well as maintain proper internal controls and risk management
- Spearhead and participate in client/vendor/broker meetings to ensure understanding of client requirements and provide operational guidance
- Lead kick off calls for new clients/vendors and yearly open enrollments
- Ensure excellent customer service for all clients
- Develop and maintain relationships with strategic and national clients on multiple levels and across business lines
- Client rosters contained 25,000+ members
- Manage specific client operational projects; define scope, create project timeline with defined key deliverables, negotiate and complete business requirements, drive resolution of non-standard requests and communicate status of outstanding issues to client leadership teams
- Ensure adherence to performance guarantees/SLA's, state and federal compliance policies, reimbursement policies, and contract compliance.
Optum/UnitedHealthcare
Sr. Revenue Cycle Specialist
11.2016 - 11.2019
Job overview
- Direct, examine, and assess documented business operations and procedures to ensure data integrity, data security and process optimization of client healthcare claims data
- Work independently to investigate, recover, and resolve health insurance medical claims for Commercial, Medicare/Medicaid/DSNP and Military/VA national insurance companies, TPA's and other third-party clients
- Expert reviewer of health plan PNP's, SOP's, reimbursement policies and health care contracts
- Analyze large data stores to identify and solve a range of complex claims problems and issues
- Adept analysis and recovery of complex and high dollar medical claims
- Investigate and pursue recoveries on subrogation and WC claims and file management
- Initiate phone calls to members, providers, and other insurance companies to gather coordination of benefits (COB) information
- Ensure strict adherence to state and federal compliance policies, reimbursement policies, and contract compliance
- HIPAA and security trained
- Exceeded goal and budget with claims revenue recoupment of over $1,000,000+ a month for 2017-2019.
Community Health Systems/PASI
Senior Health Insurance Collection Analyst
02.2013 - 11.2016
Job overview
- Follow up and call health insurance companies and use online systems to help bring commercial, Medicare/Medicaid/DSNP & VA insurance accounts to resolution
- Examine, assess, and document claims operations and procedures to ensure data integrity/ security and process optimization
- Verify eligibility and insurance coverage for patients within the hospital system and through the health insurance portals as well as the Passport system
- Initiate phone calls to members, providers, and other insurance companies to gather coordination of benefits information to determine primary payer
- Extensive follow up and resolution of billed health insurance claims and problem solving for resolution of claims that have not been processed
- Expert in complex claims appeals and processes
- Prepare analysis of accounts with urgency to help bring insurance accounts to closure quickly
- Work as a team and assist others with their files as needed
- Interact with multiple associates, departments, and facilities
- 120% of goal for Collections in 2015
- 116% of goal for Collections in 2016.
Aetna/Coventry Health Care
Service Operation Specialist
10.2011 - 02.2013
Job overview
- Review, research & verify provider demographics through outbound calls with provider offices
- Process data management updates including rosters, correspondence, and resolve customer concerns within a fast-paced team environment
- Exceed KPI metrics and service requirements by performing over 1200 updates a month
- Extensive problem solving, analytical and data entry/PC/keyboarding skills.
Knoxville News Sentinel/E.W. Scripps Co
Recruitment Advertising Account Manager
06.2007 - 03.2011
Job overview
- Increase advertising revenue from established account base with a focus on business development by onboarding at least 10 new clients a month
- Identify and pursue ways to increase individual, client and company performance
- Manage high volume of inside/outside telephone sales calls and presentation activity
- Develop ad campaigns, layouts, write & design ad copy and prepare sales presentations
- Initiate, coordinate, and conduct formal verbal and written sales presentations
- New employee trainer and SME for 6 new hires
- 2010 overall sales were over $1,500,000 in territory
- Won the Achievers Award in December 2010 for sales excellence.
Education
University of North AlabamaFlorence, AL
B.S. from Marketing
12.1992
Skills
- Experienced Remote Worker
- Lean thinker & Innovator
- HIPAA, Government Regulations, Compliance, Fraud and Security Trained
- Revenue Cycle Management
- Data Mining & Analysis
- Payment Integrity Review
- Process Improvement and Analysis
- Leadership & Team Building
- Claims Analysis and Workflow
- Presentations, Training, PNP's and SOP's
- Extensive Medicare, Medicaid, DSNP, Military, & Commercial Health Insurance Experience
- Salesforce, Jira, Confluence
- FACETS (multiple versions), FACS, Star, Medhost, HMS, and Meditech Program Experience
- Business Intelligence
- Medical Billing, Reimbursements and Medical Contract Review
- FTP/834 Membership Files
- Root Cause Analysis
- Quality Assurance
- Audit Reporting
Timeline
Senior Payment Accuracy Specialist/Business Analyst
Cotiviti, Inc.
01.2022 - Current
Strategic/National Client Support Operations Project Manager
EyeMed Vision Care
02.2020 - 01.2022
Sr. Revenue Cycle Specialist
Optum/UnitedHealthcare
11.2016 - 11.2019
Senior Health Insurance Collection Analyst
Community Health Systems/PASI
02.2013 - 11.2016
Service Operation Specialist
Aetna/Coventry Health Care
10.2011 - 02.2013
Recruitment Advertising Account Manager
Knoxville News Sentinel/E.W. Scripps Co
06.2007 - 03.2011
University of North Alabama
B.S. from Marketing
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