Larry McDuffie
Seffner,United States
Summary
Sound knowledge of project development life cycle Possess strong technical, analytical, communication, time management, problem solving, presentation skills Extensive work in all aspects and phases of Software testing: including but not limited to analysis, developing test plans, creating test scripts, executing test cases, automation, regression testing, and delivery support Responsible for driving root cause analysis for business testing gaps and implementing solutions. Highly effective at collaborating and working with peers, customers and other stakeholders. Known for efficiency and proactive, goal-oriented planning.
Overview
16
16
years of professional experience
Work History
Configuration Claims Analyst
NTT DATA Services
Tampa, FL
12.2016 - Current
- Project Qnxt Configuration
- Evaluated original investigation reports and documents to resolve secondary concerns
- (Qnxt Project)
- Qnxt project base adding claims to system testing them for product error
- Synthesized data into comprehensive quarterly written reports for management
- Collected and tracked evidence in support of legal processes
- Conducted thorough property investigations to identify and classify damages for customer claims
- (Qnxt Project)
- Project Xcelys Configuration
- Prepare files for loading onto claims platform (Xcelys)
- Pull/ Load professional contracts into Xcelys through appropriate research and provider data load activities
- Track project plan and gather updates concerning provider data from team leads as needed
- Build pricing packages
- Load provider files and audit completion
- Build rules within Paradigm System, in coordination within State and Federal guidelines
- Monitor and test accuracy of price rules
- Reviewing and researching insurance claims to determine possible payment accuracy
- Validating Member, Provider and other Claims information
- Reviewed questionable claims by conducting agent and claimant interviews to correct omissions and errors.
- Maintained strict confidentiality with all personal data as per company guidelines.
- Interacted with clients and employees, which helped cultivate positive working relationships.
Medical Management Specialist II
Anthem
Tampa, FL
07.2008 - 03.2016
- Gathers clinical information regarding case and determine appropriate area to refer or assign case (utilization management, case management, QI, Med Review)
- Handles authorizations requests and inquiry phone calls from providers accordingly Approving or denying prior authorizations for medications or doctors as requested
- Follows appropriate procedures, policies and guidelines for checking member eligibility and authorization history
- Provide network participation status Assists in preparing and submitting letters reports and assignments as needed to meet department initiatives and objectives Knowledge and understanding for medical codes ICD- 9 ICD-10 and CPT Coding
- Provide information regarding network providers or general program information when requested
- May assist with complex cases
- Act as liaison between Medical Management and/or Operations and internal departments
- Maintains and updates tracking databases
- Prepares reports and documents all actions
- Responsibilities exclude conducting any utilization management review activities which require interpretation of clinical information.
Technical Analyst
Verizon Wireless
Tampa, FL
01.2005 - 06.2008
- Authored technical requirement documentation to suit business goals and technological limits.
- Designed and maintained consistent data collection protocols and standards across numerous databases and projects.
- Performed quality assurance and quality control assessments of support ticket fulfillment.
- Prepared technical responses to requests for quotes, assigning costs, timeframes and alternative solutions.
Education
A+ Certification -
EWRIN Technical Community College
Tampa, FL03.2009
SQL - undefined
LaSalle Computer Training
2008
Skills
- Xcelys
- QNXT
- Facets
- ODRS
- Redcap
- Genesis
- SQL
- MySQL
- SAS
- PubMed
- NQF- National Quality Forum
- CMC Measures Inventory
- Claims Evaluations
- Customer Satisfaction
Timeline
Configuration Claims Analyst
NTT DATA Services
12.2016 - Current
Medical Management Specialist II
Anthem
07.2008 - 03.2016
Technical Analyst
Verizon Wireless
01.2005 - 06.2008
A+ Certification -
EWRIN Technical Community College
SQL - undefined
LaSalle Computer Training
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