ROSALINDA GONZALES
Readington,NJ
Summary
Detail-oriented analyst with exceptional communication and project management skills. 8 year commitment to resolve and detect root causes to prevent a future trend related to the No Surprise Act. Proven ability to handle multiple tasks efficiently in fast-paced environments. Recognized for taking proactive approach to identifying and addressing issues, with focus on optimizing processes and supporting team objectives. Connect with sources to implement on agreements and processes to optimize workflows and decrease audit errors
Overview
8
8
years of professional experience
Work History
Business Analyst II- NSA Pricing Configuration
Centene
05.2024 - Current
- Interacted with internal customers to understand business needs and translate into requirements and project scope.
- Optimized data access and storage to improve performance of analytics systems.
- Pull and handle Fair Health rates and medicare fees for the NSA ONR/IDR process.
- Grab data from SQL and create excel reports to monitor and track key performance indicators.
- Identified patterns and trends in large data sets and provided actionable insights.
- Collaborated with stakeholders to identify business needs and data sources.
- Testing and collaborating with developers to advance our Fair Health Rate programs.
- Developed and implemented data governance policies and procedures.
- Developed and maintained data warehouses and data marts to support business operations.
- Developed complex dashboard and reporting tools to track business performance metrics.
- Analyzed data to identify root causes of problems and recommend corrective actions.
- Updated and developed scripts and queries to extract and analyze data from multiple sources.
ONR/IDR Business Analyst
Centene Corporation
01.2023 - 05.2024
- Audit check run and send NSA related claims to the claims department for corrections. Collaborate with the claims department to price pended claims correctly. Identify authorization issues and trends and research for potential configuration-related work process changes.
- Collaborate with various business units to resolve claims issues to ensure prompt and accurate claims adjudication. Document, track, and resolve all plan providers' claims projects. Research the claims on various reports to determine if it is appropriate to move forward with recovery.
- Educate analysts on the No Surprise Act such as the Open Negotiation Request and Independent Dispute Resolution.
- Triage and validate disputes for ONR.
- Lead meetings with various departments to assign claim project priorities and monitor days in step processes to ensure the projects stay on track.
- Support business initiatives through data analysis, identification of implementation barriers, and user acceptance testing of new systems.
- Perform detailed analysis on assigned projects, recommend potential business solutions, and assist with implementation. Identify and analyze user requirements, procedures, and problems to improve existing processes.
Grievance & Appeals Coordinator
AZ Complete Health
10.2021 - 01.2023
- Gather, analyze, and report verbal and written member and provider complaints, grievances, and appeals.
- Prepare response letters for member and provider complaints, grievances, and appeals.
- Maintain files on individual appeals and grievances.
- Support the pay-for-performance programs, including data entry, tracking, organizing, and researching information.
- Assist with HEDIS production functions including data entry, calls to provider offices, and claims research.
- Manage large volumes of documents including copying, faxing, and scanning incoming mail.
- Responded to attorney inquiries and litigation notices.
- Coordinated with senior specialist to compose appeal responses.
- Acted as a departmental resource on appeals matters.
- Created, composed and maintained appeal response templates.
Senior Claims Support Analyst for Ambetter
Centene Corp
01.2019 - 10.2021
- Managed service follow-up communications, confirming satisfactory resolution of customers' service requests via email and phone.
- Monitored helpdesk and responded to incoming tickets to address support needs.
- Interacted with clients and employees, which helped cultivate positive working relationships.
- Maintained strict confidentiality with all personal data as per company guidelines.
- Identified insurance coverage limitations with thorough examinations of claims documentation and related records.
- Reviewed provider coding information to report services and verify correctness.
- Used administrative guidelines as resource or to answer questions when processing medical claims.
- Managed large volume of medical claims on daily basis.
Claims Analyst
Centene Corp
07.2017 - 01.2019
- Assured timely verification of insurance benefits prior to patient procedures or appointments.
- Processed and recorded new policies and claims.
- Managed large volume of medical claims on daily basis.
- Maintained knowledge of benefits claim processing, claims principles, medical terminology, and procedures and HIPAA regulations.
- Paid or denied medical claims based upon established claims processing criteria.
- Verified patient insurance coverage and benefits for medical claims.
- Monitored and updated claims status in claims processing system.
- Calculated adjustments, premiums and refunds.
- Checked documentation for accuracy and validity on updated systems.
Education
Bachelor of Science - Software Engineering
Southern New Hampshire University
Hooksett, NH05-2028
Skills
- Microsoft Office Suite
- SQL Update
- Proficient in Oracle & Snowflake
- Analyze data in Power BI
- Use JIRA for daily tasks
- Implement various solutions via business document requirements
- KPI tracking
- Utilize ServiceNow
- SAP
- Workflow optimization
Personal Information
Citizenship: US Citizen
Languages
English
Native or Bilingual
Spanish
Professional Working
Timeline
Business Analyst II- NSA Pricing Configuration
Centene
05.2024 - Current
ONR/IDR Business Analyst
Centene Corporation
01.2023 - 05.2024
Grievance & Appeals Coordinator
AZ Complete Health
10.2021 - 01.2023
Senior Claims Support Analyst for Ambetter
Centene Corp
01.2019 - 10.2021
Claims Analyst
Centene Corp
07.2017 - 01.2019
Bachelor of Science - Software Engineering
Southern New Hampshire University
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