Overview
Work History
Education
Skills
Timeline
Generic

Nicholas Lavergne

Rosharon

Overview

28
28
years of professional experience

Work History

Sr. Business Process Analyst

United Healthcare
Houston
01.2023 - 05.2025
  • Responsible for facilitating audits, identifying process improvements, update project plans and prepare documentation and presentation materials detailing implementation and other support initiatives.
  • Fully versed and trained on the HEDIS audit requirements and deliverables including the HEDIS Roadmap, and any other required trainings as directed.
  • Support work with external auditors, health plans, IT, quality teams, and other teams as necessary, to ensure project deliverables are met.
  • Assisting with the coordination and completion of project and deliverables across various functional areas.
  • Monitor projects and deliverables to support on time and in scope completion.
  • Document and track issues to ensure resolution with auditor.
  • Participate in various post-implementation calls and activities.
  • Identify and escalate risks.
  • Attend all required meetings.
  • Assisting with all HEDIS Roadmap readiness and completion activities.
  • Review annual HEDIS Roadmap for updates or changes.
  • Identify internal subject matter experts (SME) to complete designated HEDIS Roadmap sections.
  • Schedule HEDIS Roadmap engagement meetings with identified SMEs.
  • Attend HEDIS Roadmap engagement meetings as required.
  • Distribute HEDIS Roadmap to identified SMEs for completion.
  • Review completed HEDIS Roadmaps for accuracy prior to auditor submission.
  • Assist with preparing HEDIS Roadmap documents for submission to auditors.
  • Contributing to all audit review tasks and objectives.
  • Reviewing documentation requests received from auditors.
  • Send needed documentation requests to internal partners.
  • Ensure return of needed documentation from internal partners.
  • Review audit agendas.
  • Identify internal participants for audits as required.
  • Facilitate Audit Reviews.
  • Update project plans and prepare documentation and presentation materials detailing implementation and other support initiatives.
  • Identify process improvement opportunities and design/implement solutions as required by Audit Manager.
  • Conduct analysis of retrospective operations and engage teams to identify improvements.

Provider Relations Advocate

Optum Health
Houston
01.2022 - 01.2023
  • Accountable for the full range of provider relations and service interactions within UHG, including working on end-to-end provider claim and call quality, ease of use of physician portal and future service enhancements, and training & development of external provider education programs.
  • Acts as the liaison between Optum and participating providers by responding to provider needs and inquiries and educating providers and their office staffs.
  • Conducted service calls as requested by the provider and addressed issues that may have had negative impacts through in-servicing/training providers who demonstrate practice patterns that are not cost-effective to the organization.
  • Scheduled, coordinated, and conducted new provider orientation/training for all products.
  • Maintained contract requirements by completing appropriate forms and obtaining attendance logs for each visit.
  • Performed in-services/training, with frequency as detailed by department policy, for providers for the purpose of communicating policy changes.
  • Educated providers about provider manuals, directories, and on-line provider resource tools.
  • Coordinated with internal departments such as claims, medical management, provider services, credentialing, and EDI departments to investigate provider complaints related to care and/or services provided, and access.
  • We assist in provider claims escalations for proper project resolution with other teams’ provider claims and help enhance call quality.
  • Assist in efforts to enhance ease of use of physician portal and future services enhancements.
  • Contribute to design and implementation of programs that build/nurture positive relationships between the health plan, providers, and practice managers.
  • Support development and management of provider networks.
  • Identify gaps in network composition and services to assist network contracting and development teams.
  • Assuring our members have access to quality, affordable and quality healthcare.

Clinical Complaints Auditor

Optum Health
Houston
11.2016 - 01.2022
  • I provide expertise or general support in reviewing, researching, investigating, negotiating, and resolving all types of complaints/grievances.
  • Coordinating efforts with other areas, as necessary.
  • Communicating issues, implications, and decisions with appropriate parties.
  • Analyzing and identifying trends for complaints/grievances.
  • Ensuring optimal performance re: timely, accurate, effective, and complete responses.
  • Verifying that all documentation, letters, and attachments meet customer, regulatory and internal requirements.
  • Preparing for and participating in audits.
  • Organizing, checking, pulling, reviewing, and saving files.
  • Maintaining positive working relationships with internal and external customers including regulators.
  • Other duties as assigned.

Customer Care Professional Bar/Intake/Claims Public Sector SME

Optum Health
Houston
08.2012 - 10.2016
  • I am responsible for answering incoming calls from customers while ensuring a high level of customer service and maximizing productivity as a telecommuter.
  • Respond to complex customer calls.
  • Resolve customer service inquiries which could include:
  • Benefit and Eligibility information
  • Billing and Payment issues
  • Customer material requests
  • Physician assignments
  • Authorization for treatment
  • Explanation of Benefits (EOB)
  • Provide excellent customer service.
  • Constantly meet established productivity, schedule adherence, and quality standards.
  • Assist with escalations for supervisor.
  • Programs used: Iset, Linx, CSP Facets, CSP Maccess, CareOne, OneTool, PASS, Citrix, IBM PCOMM, EDSS, IDRS, SURF, CARTA, UNET, COSMOS, CBS, WebTRAX, C-Portal, SharePoint, EPUF, IBAAG, MACROS, Medicare, Medicaid, Health Plan, and Employer Group books of Business.

Case Manager Supervisor

Workforce Solutions
Bay City
09.2010 - 02.2012
  • I directly supervised and evaluated the performance of line staff members to increase general labor market knowledge.
  • I help develop their competence in applying that knowledge to help Workforce Solutions serve its customers.
  • By me identifying the root cause of problems and implementing solutions I was able to streamline the overall workflow within the office.
  • My department beat the office performance goals by 35%.
  • Customer complaints reduced by 85% overall from the previous 3 years.
  • Responsible for appropriate personnel actions including salary review, improvement plans and disciplinary actions.
  • Managed staff and align work with Workforce Solutions Mission.
  • Participated in hiring decisions.
  • Communicated expectations and priorities to line staff.
  • Lead, coached and mentored in line staff (15 people).
  • Monitored staff time and leave.
  • Coordinated work with other Supervisors in the organization to provide synergies.

Case Manager Supervisor

Neighborhood Center Inc.
Houston
11.2008 - 07.2010
  • Managed a group of 8 to 10 case managers assisting clients in Hurricane IKE recovery.
  • Extensive auditing of all case manager files.
  • Held weekly meetings with team.
  • Attending weekly management meeting where reports were due.
  • Responsible for producing auditing methods that met compliance with grant.
  • Very flexible in a demanding and constantly changing program.
  • Responsible for personnel actions including salary review, improvement plans and disciplinary actions.
  • Participated in hiring decisions.
  • Communicated expectations and priorities to line staff.
  • Monitored staff time and leave.
  • Coordinated work with other Supervisors in the organization to provide synergies.

Special Programs Coordinator

Salvation Army Boy’s and Girl’s Club
Houston
10.2006 - 09.2008
  • Implement grant related programs.
  • Oversee grant related programs and make sure they meet all grant requirements.
  • Manage special events that occur, i.e., Building of a playground by a non-profit organization, special events by the Houston comets, etc.
  • Managed approximately 12 to 15 employees at several locations to assure that grant programs were being operated correctly.

Case Manager / Case Manager Supervisor

TeaBird Community Services
Beaumont
05.2001 - 06.2006
  • Assessed Juveniles based on a daily point scale to determine privileges and goals attained.
  • Set out a daily plan for aides to follow for daily activities of juveniles based on their level and privileges attained.
  • Made sure any appointments juveniles needed were made whether with doctors, meetings, or counseling.
  • Participated in hiring decisions.

Texas Works Advisor I/II

State of Texas- Department of Human Services
Houston
10.1997 - 04.2001
  • Accurately determines eligibility for TANF, Food Stamps and/or Medicaid Programs.
  • Work involves interviewing clients, documenting information gathered, determining benefits, verifying case data, explaining program benefits and requirements.
  • Reviews eligibility of clients for ongoing services.

Education

Master’s Degree - Master of Business Administration

Lamar University
Beaumont, TX
05.2023

Bachelor’s Degree - Criminal Justice

Lamar University
Beaumont, TX
05.1997

Skills

  • Business process mapping
  • HEDIS auditing
  • Project management
  • Documentation preparation
  • Process improvement
  • Provider relations

Timeline

Sr. Business Process Analyst

United Healthcare
01.2023 - 05.2025

Provider Relations Advocate

Optum Health
01.2022 - 01.2023

Clinical Complaints Auditor

Optum Health
11.2016 - 01.2022

Customer Care Professional Bar/Intake/Claims Public Sector SME

Optum Health
08.2012 - 10.2016

Case Manager Supervisor

Workforce Solutions
09.2010 - 02.2012

Case Manager Supervisor

Neighborhood Center Inc.
11.2008 - 07.2010

Special Programs Coordinator

Salvation Army Boy’s and Girl’s Club
10.2006 - 09.2008

Case Manager / Case Manager Supervisor

TeaBird Community Services
05.2001 - 06.2006

Texas Works Advisor I/II

State of Texas- Department of Human Services
10.1997 - 04.2001

Master’s Degree - Master of Business Administration

Lamar University

Bachelor’s Degree - Criminal Justice

Lamar University

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Nicholas Lavergne