Michele Simard
Goffstown,USA
Summary
Dynamic and motivated team player with over 20 years of insurance experience in both Commercial and Government Business Divisions, specializing in Medicaid Market benefits. Proven track record in driving process improvements that enhance operational efficiency and accuracy. As a seasoned corporate trainer, delivered impactful training programs that resulted in successful onboarding of new hires. Renowned for strong analytical and communication skills that support team success and client satisfaction.
Overview
23
23
years of professional experience
Work History
Senior Business Analyst
Wipro Limited
East Brunswick, NJ
08.2024 - Current
- Researches and analyzes Medicaid guidelines to facilitate configuration updates to ensure claim processing accuracy.
- Identifies complex user needs to provide lasting solutions to stakeholder challenges.
- Completes ongoing maintenance of Facets and Benefit Requirements Documents to ensure market stakeholders, members, and providers have access to the most current, and accurate benefit data.
- Pinpoints inefficiencies in business processes, and develops and implements improved policies.
- Maintains and updates internal tracking databases.
- Serves as a consultant to Medicaid partners (Health Plan, Utilization Management, AIM/MPTAC, Cost of Care, Value-Added Benefits, Quality, and Configuration).
- Assists with team training, successfully onboarding seven new hires at Wipro.
- Collaborates with IT developers to design and implement tool requirements, testing, and governance.
Benefit Analyst III
Anthem BCBS
Manchester, NH
09.2002 - 07.2024
- Provided ongoing maintenance of Benefit Requirements Documents and Facets Benefit Summaries.
- Developed and implemented a quality auditing program for new and existing analysts.
- Looked to as a Medicaid Subject Matter Expert to provide ongoing guidance and support to both internal and external partners.
- Provided training and support to team members on benefits administration best practices.
- Provided support for internal and external tools, including requirement building and UAT testing.
Business Analyst II
Reimbursement Methodology/Source Solutions Governance - GBD
03.2020 - 07.2022
- Performed extensive Medicaid market reviews of benefit coverage and reimbursement.
- Reviewed and interpreted clinical records to ensure accurate claim reimbursement determination.
- Maintained the GAP Fee Schedule to ensure accurate code reimbursement, resulting in a reduction of over/under payments and provider abrasion.
- Designated team trainer for onshore and offshore associates in both classroom and one-on-one settings.
- Developed a training program, including policies, processes, and job aids, resulting in an average of 95% quality audit scores upon program completion.
- Assisted with performance monitoring and evaluation by creating and implementing the department's Quality Audit program.
- Initiated various process improvement projects, resulting in higher accuracy and reduced TAT.
Cost of Care Analyst I – Documentation Specialist
Reimbursement Methodology - GBD
09.2019 - 03.2020
- Identified, documented, and implemented process guidelines, policies, and job aids to streamline responsibilities and reduce turnaround times.
- Collaborated with the leadership team to identify, review, and resolve departmental challenges.
- Created annual team goals and analyst scorecards.
- Facilitated team meetings and recorded minutes.
- Utilized Visio to create swim charts and process flows for visual aids to understand E2E processes.
- Redesigned the department's SharePoint site to create a more efficient and organized resource for team members.
Service Rep/Analyst
JAA - Jointly Administered Accounts
04.2018 - 09.2019
- Managed daily reports and communicated findings to senior leadership.
- Completed root cause analysis of adjustment fallout, and implemented solutions to ensure JAA Fund satisfaction.
- Responsible for a million-dollar claim, pre-pay research, and resolution.
- Established and maintained successful relationships with fund representatives, including educating them on best practices, resulting in reduced fund errors and turnaround time.
- Reduced a backlog of approximately 20,000 aged adjustments on hand within one month by automating and fine-tuning the adjustment process.
Financial Ops Recovery Spec II
Commercial Blue Card Unit
02.2002 - 04.2017
- Reviewed accounts receivables and completed associated claim adjustments.
- Collaborated with providers and Plan 2 Plan associates to validate claim data accuracy.
- Ensured successful claims processing in accordance with claim coding, policies, and procedures.
- Maintained positive provider relationships, and acted as a single point of contact for support.
- Collaborated with leadership to track and trend inventories.
- Responsible for triaging and distributing department responsibilities.
Claims Clerk
Cigna Healthcare
Concord, NH
10.2001 - 02.2002
- Evaluated incoming documents for completeness and accuracy prior to entering into system database.
- Transcribed data to worksheets and entered data into computer to prepare departmental documents.
Education
Some College (No Degree) - Business Administration And Management
University of New Hampshire
Manchester, NHSkills
- Consulting
- Change management
- Microsoft Office
- Training
- Analysis
- Documentation
- Written and oral communication
- Quality Auditing
- Vendor management
- Tool requirement writing and testing
- Project management
- Process development and improvement
References
References available upon request.
Timeline
Senior Business Analyst
Wipro Limited
08.2024 - Current
Business Analyst II
Reimbursement Methodology/Source Solutions Governance - GBD
03.2020 - 07.2022
Cost of Care Analyst I – Documentation Specialist
Reimbursement Methodology - GBD
09.2019 - 03.2020
Service Rep/Analyst
JAA - Jointly Administered Accounts
04.2018 - 09.2019
Benefit Analyst III
Anthem BCBS
09.2002 - 07.2024
Financial Ops Recovery Spec II
Commercial Blue Card Unit
02.2002 - 04.2017
Claims Clerk
Cigna Healthcare
10.2001 - 02.2002
Some College (No Degree) - Business Administration And Management
University of New Hampshire
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