Nilsa M Nunez
Summary
Master's degree graduate offering a strong academic and professional background in Healthcare with over 17 years experience in medical claims and regulatory compliance. Expertise in root cause analysis and implementation of targeted processes to improve quality assurance.
Overview
17
17
years of professional experience
Work History
HEDIS Quality Improvement Project Lead
AvMed Health
02.2020 - Current
- Provide leadership, coordination, and management of HEDIS, and Stars for measures as assigned
- Assist in Quality Improvement projects
- Collecting, analyzing, interpreting, and reporting health care data to senior leadership in order to meet accreditation requirements
- Support statewide activities and projects that focus on achieving goals of quality care
- Monitoring and evaluating healthcare delivery systems and effectively implementing the application of Quality Improvement principles and practices within the organization.
Quality Assurance Supervisor
07.2015 - 01.2020
- Oversee Quality Assurance for claims Operations while successfully managing the effectiveness of the claims processing functions.
- Conduct all yearly regulatory audits while maintaining overall quality and adhering to compliance and State and Government regulations.
- Responsible for maintaining overall Quality of claims processing services.
- Assist with the development of the memorandum of Understanding contract language for delegated entities.
- Prepare reporting and documentation for audit compliance.
- Ensure that quality standards are in compliance with State and Federal regulations.
- Played an integral role in identifying and transitioning work to outsourced vendors as well as redesigned operational processes for a much more improved training program.
- Implemented new coaching and training programs to develop staff, facilitate efficiency, and improve performance.
Senior Claims Analyst
Beacon Health Options
Miami, FL
01.2012 - 07.2015
- Audit 6% of daily process work.
- Prepare yearly client audits.
- Develop and prepare duplicate claim payments reports.
- Responsible for weekly closing batch.
- Research and process all claim grievances and appeals within 30 days of receipt.
- Process refund payments and apply credit memos.
- Backup claims supervisor and assist department manager as needed.
- Prepare policies and procedures for all lines of business.
- Maintain current training manual and comply with all existing training as needed.
Claims Examiner II
Substance abuse
Miami, FL
07.2007 - 02.2012
- Increased claims processing by completing 100-300 physician and hospital claims for mental health, Government claims, and Secondary payer and scored 100% accuracy.
- Increased productivity in processing out-of-network claims withina14-day turnaround timeframe.
- Adequately Priced out of network claims utilizing Medicare physician calculator in addition to CMS, 3M, and DRG calculators
- Performed and accurately adjudicated all types of transportation claims
- Run 837 reporting of electronic claims submission.
Intake Coordinator
Beacon Health Strategies
Miami, FL
01.2005 - 02.2007
- Answer 50-100 incoming calls daily from Members, providers, and insurance companies related to authorization of services for pre-service routine outpatient services
- Triage request for urgent-emergent appointments related to suicidal or substance abuse
- Verify benefits and input demographic information into VIS
- Assist claims dept
- With the transition of Medicaid expansion
- Research denials and assist with department overflow as well as authorizations
Education
Master of Health Administration - Health Administration
University of Phoenix
Tempe, AZ04.2021
MBA - Business Administration And Management
University of Phoenix
Tempe, AZ04.2021
Bachelor of Science - Business
University of Phoenix
Tempe, AZ05.2018
Skills
- Reliable Healthcare professional with BS, MBA background in Business and Healthcare Administration 17 years of experience in medical claims and regulatory compliance
- Policy investigations
- Benefits review
- Insurance policy coverage knowledge
- Claims
- Analytical Methodology Validation
- Quality Issue Identification
- Claims investigation and research
- Planning and Organization
- Analytical Thinking and Problem Solving
- Project Management
- Prior authorization processing
Timeline
HEDIS Quality Improvement Project Lead
AvMed Health
02.2020 - Current
Quality Assurance Supervisor
07.2015 - 01.2020
Senior Claims Analyst
Beacon Health Options
01.2012 - 07.2015
Claims Examiner II
Substance abuse
07.2007 - 02.2012
Intake Coordinator
Beacon Health Strategies
01.2005 - 02.2007
Master of Health Administration - Health Administration
University of Phoenix
MBA - Business Administration And Management
University of Phoenix
Bachelor of Science - Business
University of Phoenix
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