Summary
Overview
Work History
Skills
References
Timeline
Generic

Miguel A. Ramos Jr.

Chicago,IL

Summary

Extensive progressive diversified background in the Health Insurance Industry. Experienced in product development from concept through production. Self-starter with excellent interpersonal communication skills. Noted for meticulous attention to details.

Overview

27
27
years of professional experience

Work History

Market Finance Professional / Network Consultant

Humana Inc.
01.2012 - 01.2023
  • OV 40 Reports on a weekly basis along with Claims disposition files monthly
  • Built DART tool to help audit loading issues to ensure accuracy per fee schedule
  • Execute daily ad hoc requests using strong MS skills allocating time back to the specialists.
  • Collaborated closely with cross-functional teams to optimize resource allocation, ensuring alignment between departmental budgets and organizational objectives.
  • Increased cost savings by identifying inefficiencies in financial operations and implementing strategic solutions.

Data Analyst

Humana Inc.
01.2004 - 01.2012
  • OV 40 Reports on a weekly basis
  • Created and Maintain Gap-Fill DB for Medicare
  • Revived ChoiceCare Database
  • Created A Contestation Database.

Service Operations / Claims Analyst

Humana Inc.
01.2001 - 01.2004
  • Developed and implemented a database which reduced claims leakage producing a 2.1 million dollars in annual savings
  • Acted as market liaison in resolving complex contractual interpretation along with claims processing concerns
  • Improved communication barriers by constructing a multi-purpose tool enabling others to understand the complexity of the markets negotiating techniques.
  • Managed high-volume caseloads, prioritizing tasks to ensure timely completion of all claims.
  • Conducted thorough investigations into each claim, gathering relevant data and documentation to support decision-making processes.

Contract Manager/Provider Admin Rep. II

Humana Inc.
01.1999 - 01.2001
  • Provided 98% accuracy in Humana's provider directory by scrubbing monthly provider files
  • Improved claims payment accuracy by obtaining training seminars as well as promoting Humana's e-tools and e-technology
  • Ensured customer/client satisfaction by coordinating monthly meetings.

Member Service Representative

Health Direct Inc.
01.1998 - 01.1999
  • Produced a 98% migration of Medicare membership to Humana products by educating our members on their new health care benefits
  • Maintain high volume of all member/provider inquiries on benefit administration
  • Adjudication of claims along with coordination of benefits
  • Responsible for all claim inquiry adjustments for the member service department
  • Responsible for handling of non-contracted provider adds
  • Targeted as a team leader for member service representatives as well as the group's benefit administrator's primary contact
  • Worked on ensuring member satisfaction by reprocessing inaccurate medical as well as hospital claims
  • Assisted with the open enrollment with loading of applications during peak periods.

Claims Auditor

Health Direct Inc.
01.1997 - 01.1999
  • Achieved a 98% accuracy level in the claims unit by auditing commercial claims
  • Consistent on meeting established company deadlines on weekly and
  • Maintain auto audit reports on a daily basis before claims are finalized for payment
  • Training of new hires and reviewing of trainees work at 100%
  • Maintaining policies and procedures for adjudication of claims.

PPO Customer Service Representative

01.1997 - 01.1998
  • Worked with clients on locating participating physicians within their area
  • Repricing of PPO claims
  • Worked on contracting inquiries from providers on repriced claims.

Patient Intake Coordinator

01.1996 - 01.1997
  • Maintained 98% call answer rate with achieving less than 2% abandonment
  • Assisted case management on closing of files for discharged patients
  • Back-up person for appeals typist as well as production coordinator.

Skills

Proficient in PC based software including, SAS Programming, SQL Server Software Implementation

System Upgrades

Network Administration

MySQL

System optimization

Troubleshooting Network Issues

Organizational Skills

Database Management

Attention to Detail

Teamwork and Collaboration

Hardware and Software Repair

Remote Technical Support

Problem-Solving

Microsoft Windows and Office

System Configuration

Systems Analysis

Remote Support

System Administration

Software Development

IT Documentation

IT Troubleshooting

References

Available on request

Timeline

Market Finance Professional / Network Consultant

Humana Inc.
01.2012 - 01.2023

Data Analyst

Humana Inc.
01.2004 - 01.2012

Service Operations / Claims Analyst

Humana Inc.
01.2001 - 01.2004

Contract Manager/Provider Admin Rep. II

Humana Inc.
01.1999 - 01.2001

Member Service Representative

Health Direct Inc.
01.1998 - 01.1999

Claims Auditor

Health Direct Inc.
01.1997 - 01.1999

PPO Customer Service Representative

01.1997 - 01.1998

Patient Intake Coordinator

01.1996 - 01.1997

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Miguel A. Ramos Jr.