Summary
Overview
Work History
Education
Skills
Timeline
Generic

Lydia Lago

Anaheim,CA

Summary

Analytical Policy professional familiar with reviewing regulations, legislation and policies. Excellent in research, background completing in-depth reviews under tight timelines to evaluate current, pending and proposed changes. Well-versed in authoring reports and developing recommendations to departmental areas within Health Care. Over fifteen years of experience in the healthcare industry and years of policy management.

Overview

15
15
years of professional experience

Work History

Program Policy Analyst Sr.

CalOptima
05.2020 - 10.2022
  • Recommended updates to current legislation, regulations and policies.
  • Identified, evaluated and developed solutions to remove roadblocks to change.
  • Drafted and presented reports outlining policy actions.
  • Investigated policies currently under discussion to assess impact to the health plan.
  • Checked documentation for accuracy and validity on updated systems.
  • Reviewed audit and monitoring reports related to consumer and client activities.
  • Stayed current with latest changes to applicable regulatory standards and company procedures.
  • Prepared documentation and records for upcoming audits and inspections.
  • Supported and trained employees on compliance-related issues.
  • Developed improvement and corrective action plans to bring operations in line with requirements.
  • Performed deep audits of Government Programs to assess compliance with industry standards.

Privacy Analyst Sr.

L.A. Care Health Plan
01.2020 - 05.2020
  • Evaluated current processes to develop improvement plans.
  • Produced detailed and relevant reports for use in making business decisions.
  • Compiled research data and gave professional presentations highlighting finds and recommended optimizations.
  • Reviewed internal systems and organized training plans to address areas in need of improvement.
  • Implemented improvement initiatives and developed compliance testing program to monitor and identify gaps in new and existing practices.
  • Coordinated with executive leadership on strategic initiatives relating to member information, privacy protections and alignment among data privacy and security activities.
  • Tracked metrics involving critical incidents (PHI) to model trends, produce reports and make effective recommendations for improvements.
  • Gathered data from incidents that had been remedied for careful review and analysis to prevent future events.
  • Handled high priority incidents with exceptional poise and composure, making quick decisions in effort to reduce overall impact.
  • Conducted Audits for PHI violations (Audit Walkthrough)

Billing Analyst

Healrh Care Support
10.2019 - 01.2020
  • Analyze and interpret contracts to determine if Drugs were rebate eligible.
  • Responsible for accurate and timely processing of pharmaceutical rebates.
  • Maintaining contract databases in the rebate billing system.
  • Verifying rebate eligibility by client formulary and line of business.
  • Works with Industry Relations, Client Management, Clinical Services and assigned Pharmaceutical Manufacturers.
  • Identify rebate eligibility and formulary information
    Works with Rebate Accounting to identify issues to payment collection and reconciliation
  • Prepared invoices on bi-weekly basis, effectively sending out bills for upwards of fifteen pharmaceutical customers monthly.
  • Mentored new hires, resulting in stronger staff development and increased productivity.
  • Assessed student needs to develop effective training plans.
  • Proved successful working within tight deadlines and fast-paced atmosphere.
  • Used critical thinking to break down problems, evaluate solutions and make decisions.

Technical Policy Lead

Horizon Blue Cross Blue Shield Of NJ
12.2015 - 10.2019
  • Prepare ODAG/CDAG audits, present in CMS and Internal audits.
  • Appeals, Grievance and CTM monitoring.
  • Performed system analysis, documentation, testing, implementation and user support for platform transitions.
  • Documented procedures and business processes and shared information with appropriate stakeholders.
  • Work with internal business units to identify gaps, develop and implement corrective action plans and facilitate monitoring activities to ensure we remain compliant.
  • Participate in work sessions with cross-function teams including internal business units and/or external entities to correct performance deficiencies.
  • Assists with the investigation and statement of problems.
  • Escalates issues as appropriate
    Conduct User Acceptance Testing (UAT) for system fixes.
  • Analyze Medicare Ch. 2, 3, 4, 13, as well as Marketing guidelines to determine necessary updates within Medicare Operations.
  • Medicaid/DSNP Grievance and Quality Review
  • Trained new team members by relaying information on company procedures and safety requirements.
  • Evaluated employee skills and knowledge regularly, training and mentoring individuals with lagging skills.
  • Took on additional job duties during unexpected backlog, resulting in meeting project target date.
  • Maintained current understanding of local, state and federal guidelines for emergency response.

Medicare Business Analyst

Horizon Blue Cross Blue Shield Of NJ
01.2013 - 12.2015
  • Conducted interviews with key business users to collect information on business processes and user requirements.
  • Analyzed key aspects of business to evaluate factors driving results and summarized into presentations.
  • Applied honed problem-solving skills to analyze and resolve issues impacting business operations and goal achievement.
  • Improved business direction by prioritizing customers and implementing changes based on collected feedback.
  • Identified and resolved problems through root cause
  • analysis and research.
  • Remained knowledgeable regarding company policies and procedures and current developments within operational departments.
  • Process Daily CMS transaction from Transaction Reply Report.
  • Audit Late Enrollment Penalty accounts.
  • Create/Submit Maximus case files .

Business Analyst

Rangam - Horizon Blue Cross Blue Shield Of NJ
08.2011 - 01.2013
  • Reconcile records for delinquent account members, outreach calls for billing issues.
  • Identified, researched and resolved billing variances to maintain system accuracy and currency.
  • Review accounts and Center for Medicare Systems (CMS) to ensure member Prescription coverage.
  • Initiate Late Enrollment Penalty (LEP) process by sending attestations to members, receive and review returned attestations for accuracy before sending to Center for Medicare.
  • Conduct Quality review of my peers work.
  • Conduct account reviews to ensure members are being billed accurately and issues of refunds.
  • Process Daily Transaction Reply Report
    Partake in CMS Audits
  • Partake in Regulatory Audits.

Medicaid Enrollment Unit Reconciliation Analyst

Access Staffing VNSNY
New York, NY
05.2010 - 05.2011
  • Maintained excellent attendance record, consistently arriving to work on time.
  • Tracked members who lost Medicaid status and assisted with reinstatements.
  • Conducted financial screening and documentation gathering for clients to determine qualification for payment programs.
  • Investigated issues and created solutions for new customers.
  • Maintained detailed and accurate records between multiple databases and programs.
  • Optimized system and platform performance capabilities in most efficient, practical way possible.
  • Collect and update yearly Net Available Monthly Income (NAMI) for members.
  • Assisted with tracking NYSARC payments for members.
  • Processed plan to plan payments & P2P collections based on CMS plan reconciliation report.
  • Create the sales agent payment breakdown report.
  • Update and maintain tracking of our out of are and request for information report and updating the weekly Transaction Reply report.

Customer Service Representative

TMG Health
Scranton, PA
2007.09 - 2010.04
  • Maintained customer satisfaction with forward-thinking strategies focused on addressing customer needs and resolving concerns.
  • Provided primary customer support to internal and external customers regarding benefits.
  • Offered advice and assistance to customers, paying attention to special needs or wants.
  • Updated account information to maintain customer records.
  • Clarified customer issues and determined root cause of problems to resolve product or service complaints.
  • Answered customer telephone calls promptly to avoid on-hold wait times.
  • Used company troubleshooting resolution tree to evaluate technical problems and find appropriate solutions.
  • Handled over Fifty calls per shift signing up new customers, retrieving customer data, presenting relevant product information and cancelling services.
  • Submitted verbal and written notification to members and providers.
  • Remained knowledgeable regarding company policies and procedures and current developments within operational departments.

Education

Bachelor of Arts - Health Care Admin

University Of Phoenix
05.2014

Skills

  • New Policies Processing
  • Compliance Reporting
  • User Acceptance Testing (UAT)
  • Audit Coordination
  • Audit Monitoring
  • System Improvements
  • Policy Modifications and Updates
  • Policy Drafting
  • Training Policy Development
  • Active Listening
  • Time Management
  • Tracking Metrics
  • Corrective Actions
  • Business Development
  • Business Analysis
  • Regulatory Compliance Adherence
  • Privacy and Confidentiality
  • Project Requirements
  • Data Integrity
  • Operational Efficiency
  • Training Initiatives
  • Complaint Response
  • Regulatory and Compliance Understanding

Timeline

Program Policy Analyst Sr.

CalOptima
05.2020 - 10.2022

Privacy Analyst Sr.

L.A. Care Health Plan
01.2020 - 05.2020

Billing Analyst

Healrh Care Support
10.2019 - 01.2020

Technical Policy Lead

Horizon Blue Cross Blue Shield Of NJ
12.2015 - 10.2019

Medicare Business Analyst

Horizon Blue Cross Blue Shield Of NJ
01.2013 - 12.2015

Business Analyst

Rangam - Horizon Blue Cross Blue Shield Of NJ
08.2011 - 01.2013

Medicaid Enrollment Unit Reconciliation Analyst

Access Staffing VNSNY
05.2010 - 05.2011

Customer Service Representative

TMG Health
2007.09 - 2010.04

Bachelor of Arts - Health Care Admin

University Of Phoenix

Similar Profiles

CREATE PROFILE
Lydia Lago