Josh Vaught
New Albany,IN
Summary
Thorough team contributor with strong organizational capabilities. Experienced in handling numerous projects at once while ensuring accuracy. Effective at prioritizing tasks and meeting deadlines.
Demonstrates strong analytical, communication, and teamwork skills, with proven ability to quickly adapt to new environments. Eager to contribute to team success and further develop professional skills. Brings positive attitude and commitment to continuous learning and growth.
Experienced with Medicare regulations and patient support. Utilizes skills in claims processing and compliance to ensure smooth and efficient operations. Track record of effective communication and teamwork, contributing to organizational success.
Overview
27
27
years of professional experience
Work History
Business Consultant
Humana Inc.
New Albany, IN
09.2007 - Current
- Provide guidance on Original Medicare rules and regulation, reimbursement and billing guidelines to both internal and external customers
- Responsible for providing impacts on claims and provider process and services (aka PNO) (if any) to our CMSCMU (Contract Management Unit) regarding changes we have received from CMS
- Approver of claims process documents for claims adjusters
- Stakeholder in our claims payment policies
- Stakeholder in our code editing policies
- Developed business strategies by conducting comprehensive market research and competitor analysis.
- Helped meet changing demands by recommending improvements to business systems or procedures.
- Led process improvement initiatives that resulted in streamlined workflows and increased overall efficiency within the organization.
- Participated in regular audits to ensure compliance with industry standards, regulations, and internal policies regarding mainframe systems operation.
- Maintained up-to-date knowledge of industry regulations, ensuring compliance with all relevant guidelines and legislation.
Provider Service Relation
Humana Inc.
01.2007 - 09.2007
- Responsible for maintaining/building the relationships with our providers in Northern Region Market providers
- Provided a better understanding of Medicare to Provider Service Relation, Contractor, Market Representatives, and the provider community
- Monthly conference call with provider to go over ongoing issues
Team Lead for CRU
Humana Inc.
01.2005 - 01.2007
- Responsible for keeping the Cru unit up-to-date with accurate and precise claims processing guidelines
- Helped bridge the Gap between Cru and CSR
- Run the daily report for the unit, so they know where we stand as a unit
- Help my supervisor with Side-By-Sides each month.
- I provide the market, members, and providers with call back if an escaladed issue comes to our unit. Just so that they have a true understanding of what is going on with the situation
- Created the Medicare Call/Cru database. I plan for this database to help Customer Service answer any claims that they may not have an answer to that they are not accustom to and for Cru; I plan for this to help them answer an claims questions that they may have without having to dependent on me for the answer
- I volunteer myself to help other units out when they are in need of help, but only after I have completed my work loaded for my team first
Claims Research Analyst
Humana Inc.
01.2003 - 01.2005
- Responsible for making proper adjustments according to the member benefit, providers contact and Humana Policies and Processes
- Trained all Medicare associates on how to process PPS (Prospective Payment System) claims
- Exceeded production on a daily basis. Goal is 45 a day. I achieved 65+ with excellent quality
Claims Adjuster
Humana Inc.
01.2001 - 01.2003
- Responsible for paying the claims with 100% quality
- Keep our pends aging to date as low as possible
- Was part of the team that produced the encounter baseline processed for the Med Risk team and processes
- Trained all new associates on the Medicare product once in the unit
Data-Entry
Humana Inc.
01.1999 - 01.2001
- Was responsible for keying in the data accurately for claims adjuster to process the claims
Education
Indiana University Southeast
01.1999
Skills
- 26 years’ of successful experience in the Health Care Industry
- 26 years' of experience with Humana systems
- Comprehensive knowledge of Medicare compliance standards
- Data-driven business analysis
- Risk mitigation strategies
- Quality assurance and control
- Process improvement
- Cost reduction
- Data analytics
Accomplishments
- Received a Star Award for assistance with Decatur County Hospital
- Received a Star Award for filling in while supervisor was out on Medical leave took on supervisor responsibility
Timeline
Business Consultant
Humana Inc.
09.2007 - Current
Provider Service Relation
Humana Inc.
01.2007 - 09.2007
Team Lead for CRU
Humana Inc.
01.2005 - 01.2007
Claims Research Analyst
Humana Inc.
01.2003 - 01.2005
Claims Adjuster
Humana Inc.
01.2001 - 01.2003
Data-Entry
Humana Inc.
01.1999 - 01.2001
Indiana University Southeast