Summary
Overview
Work History
Education
Skills
Timeline
Generic

NICOLE SWINSON

Peoria,USA

Summary

Results-oriented Claim Business Process Consultant with expertise in problem-solving and data analysis across multiple business lines including MnR, E&I, IFP, and Community and State. Proven track record in issue resolution and end-to-end root cause analysis, enhancing operational efficiency and addressing complex claims challenges. Skilled in stakeholder engagement and utilizing Power BI for actionable insights, leading to improved financial performance and client satisfaction. Focused on process optimization and performance improvement strategies, ensuring effective integration of innovative solutions into business operations.

Overview

9
9
years of professional experience

Work History

Claim Business Process Consultant / VBR

United Healthcare
01.2023 - Current
  • Developed strategies to address operational performance issues effectively.
  • Conducted root cause analyses on complex problems affecting efficiency.
  • Managed processes for Value-Based and Capitated Provider groups, ensuring regulatory compliance.
  • Presented monthly performance data to stakeholders to support informed decision-making.
  • Facilitated OEM and IPOC meetings, promoting collaboration for improved outcomes.
  • Monitored impacts on care providers and member experiences using Power BI and Excel.
  • Collaborated with executives to establish transparent relationships with Delegates.
  • Resolved DOI issues promptly, ensuring correct outcomes.

Data Mining

Optum
10.2022 - 01.2024
  • Conducted data mining activities to identify trends, issues, or discrepancies in financial data.
  • Helped in the writing and steps required for job aids needed to recover claims.

Investigations and Solutions/ISG

United Healthcare
08.2021 - 10.2022
  • Achieved measurable improvements in claim handling through resolution of provider issues.
  • Facilitated system updates to significantly boost operational efficiency.
  • Collaborated with cross-functional teams to implement effective solutions.

Platinum Adjuster / SME

United Healthcare
03.2017 - 08.2021
  • Processed claims for Gold Card members with precision and accuracy.
  • Resolved complex claims swiftly, reducing overall resolution time.
  • Guided team as Subject Matter Expert in interpreting standard operating procedures.
  • Facilitated collaboration during weekly partner meetings to enhance communication.
  • Conducts root cause analysis with Power BI, deriving actionable insights for business processes.
  • Facilitates OEM and IPOC meetings, fostering collaboration for enhanced outcomes.
  • Efficiently resolves complex claim issues, ensuring client satisfaction and loyalty.
  • Partners with Delegates to align solutions with evolving business needs.
  • Analyzed data to identify overpayments, boosting financial outcomes with measurable results.
  • Conducted quality audits on claims, ensuring payment accuracy and minimizing overpayments.
  • Handled high-volume algorithm-based issues, enhancing operational efficiency.
  • Developed comprehensive job aids for algorithm processes, improving team knowledge.
  • Resolved provider issues, achieving measurable improvements in claim handling.
  • Facilitated system updates, boosting operational efficiency significantly.
  • Collaborated with teams for effective solutions, enhancing provider relations.
  • Led provider meetings, ensuring clear communication and education.
  • Exceeded resolution metrics, showcasing strong analytical problem-solving.
  • Processed claims for Gold Card Members with precision, enhancing accuracy.
  • Resolved complex claims swiftly, improving resolution time.
  • Guided team as Subject Matter Expert in SOP interpretation.
  • Facilitated effective collaboration in weekly partner meetings.
  • Boosted claim resolution efficiency through problem-solving.

Education

Project Management

UC San Diego
09-2026

Skills

  • Problem solving
  • Time management
  • Interpersonal communication
  • Multi Platform User Experience
  • Excel
  • Power BI
  • PowerPoint
  • Data analysis
  • Analytical thinking
  • In-depth claim knowledge
  • Claims processing
  • Stakeholder engagement
  • Root cause analysis
  • Teamwork and collaboration
  • Problem-solving abilities
  • Claim knowledge, all lines of business
  • Multitasking
  • Process improvement expertise
  • Problem-solving

Timeline

Claim Business Process Consultant / VBR

United Healthcare
01.2023 - Current

Data Mining

Optum
10.2022 - 01.2024

Investigations and Solutions/ISG

United Healthcare
08.2021 - 10.2022

Platinum Adjuster / SME

United Healthcare
03.2017 - 08.2021

Project Management

UC San Diego
NICOLE SWINSON