Summary
Overview
Work History
Education
Skills
Timeline
Generic

Stephanie Smith

Kyle,TX

Summary

Obtain a challenging and rewarding position, within a solid, progressive staff setting that best utilizes my experiences and training in Recovery Resolution with root cause analysis, Financial Analysis, High Dollar DRG Auditing, Provider Advocacy, FWA, Subrogation, Appeals, and Provider Contract literacy opportunity for personal and professional development within any Health Plan setting.

Overview

26
26
years of professional experience

Work History

Lead Quality Auditor Consultant

Cigna Evernorth Merged with HCSC
01.2025 - Current
  • Develop and supports a positive professional business relationship with Vendors, internal partners, and providers.
  • Work with Vendor monthly Audits from imported data from selected tables and exporting to spreadsheets and provides written and oral communications on generated reports via SharePoint in which the request from vendors is correct per the verification of contract language of DRG billed
  • Verifying network provider’s contractual agreements performing audits on the claims in which our external Vendors have agreed or disagreed with the processing on our internal claim processors.
  • Working with internal recovery department on overpayments and recoveries on Medicare claims pending claim for medical records review for the DRG billed
  • Compile and analyze data and review medical records to find the root cause analysis to provide feedback to Vendors and hospital and professional providers
  • Conduct monthly Web Ex meetings and conference calls to solve more complex issues with Vendors and discussions Reimbursement policies, new provider contracts misinterpretations, Retro contract load issues, contract renewals with CMS Medicare Billing payment guidelines and Revenue Savings
  • Collaborating with the claims team, finding process gaps to decide timely filing guidelines are being considered and improving procedures
  • Provide training for new hires on Call Trackers and all Audit Categories

Medical Claims Analyst

Aetna/CVS
01.2024 - Current
  • Review and examine Medicare Claims Authorization post and pre- release of payments for authorizations, reasonable charges, and reviewing coding to ensure denials are appropriate
  • Decide the reimbursement applying federal regulations and provider contract provisions to determine if a claim is payable
  • Auditing claims and ensuring that company reimbursement payments are accurate
  • Providing customer service internally answering questions and resolving CCR claim issues
  • Preparing reports providing detailed reporting on data such as claims volume, savings, and billed charges
  • Staying updated: Keeping up with changing laws and healthcare industry policies and regulations

Senior Network Relations Analyst

Aetna/CVS
10.2021 - 04.2023
  • Primary contact for assigned high profile provider or groups (local, individual providers, small groups/systems)
  • Delivered scrubbed rosters for provider data set up, oversee, and maintain positive relationships by assisting with or responding to complex issues about policies and procedures, plan design, contract language, service, claims or compensation issues provider education needs on scorecards and suggestions on how to obtain the score that’s needed to meet expectations Hedis
  • Optimized interactions with assigned providers internal business partners and Stakeholders to establish and maintain productive, professional relationships.
  • Monitored service capabilities and collaborate cross-functionally to ensure that the needs of the Providers are met by providing on-boarding and orientation to new providers via Web Ex Presentations monthly also encourage providers to take on-line training that provide instruction and n on processes for network participation
  • Escalated issues related but not limited to, claim payment, contract interpretation or parameters, and accuracy of provider contract or Roster Manage for demographic updates are resolved.
  • Supports or assists with submittal of Universal Rosters for the Database Management team, and Contract Team.
  • Performs credentialing verification when needed with the State of Illinois for eligibility purposes.
  • Meets with key providers monthly or as requested from the providers on complex global project issues, via Web-Ex or in person to ensure service levels are meeting expectations.
  • Managed all travel bookings and reimbursement through Concur with the appropriate valid receipts.
  • Managed the development of agenda for monthly meetings confirms material from the State and facilitates external provider meetings, cross functionally on the implementation of large provider systems and provider portal.
  • Identify trends and enlist help in provider resolution with the Provider Data Team and submitted rosters.
  • Assist with Network Management and Contracting for standard provider recruitment, contracting, reconciliation outreaches and assist with more complex contracting and discussions as needed by business segment.

Grievance and Appeal Consultant

Aetna/CVS
07.2020 - 10.2021
  • Independently review and evaluate appeal and grievance requests to find and classify member and provider appeals, using internal systems, decide eligibility, benefits, and prior activity related to the claims, payment, or service in question.
  • Work with Medical Directors make outreaches to Providers or Members in regarding appeal.
  • Make calls to members, providers, transportation companies on members injuries and complaints or Grievance and injuries and if it is an injury occurred the case needs to be escalated.
  • Independently conduct thorough investigations of all member and provider correspondence by analyzing all the issues presented and obtaining responses and information from internal and external entities. Validate the responses to ensure they address the issues and are supported by any contract stipulations, regulations, etc. as applicable.
  • Prepares cases for Medical Directors internal and external review detailing the findings of their investigation for consideration in the plan’s determination. Make recommendations on administrative decisions by preparing detailed case.
  • Summaried and reviewed all applicable benefit and contact materials. Present findings and recommendations to proper parties for sign-off.
  • Make critical decisions regarding research and investigation to appropriately resolve all inquiries.
  • Serve as liaison with Aetna Better Health of Illinois departments, vendors of specialties, delegated entities, medical groups, hospitals and in and out of network physicians to ensure timely resolution of cases.
  • Follow-up team members on audits that were conducted quarterly and assist with error changes.
  • Monitor daily and weekly pending reports and personal work-lists, ensuring internal and regulatory timeframes are met.
  • Facilitate meetings for appeals related to outside Vendors on issues that’s delaying the process of closure of a case.
  • Independently prepare professionally written, customized responses to all correspondence that appropriately and completely address the complainant’s issues and are structurally accurate.
  • Ensured responses are completed within the applicable regulatory timeframe.

Senior Reporting Analyst

United Healthcare
08.2018 - 12.2019
  • Creates ad hoc reports by using SQL queries Galaxy, and Toad Database for a variety of analysis, to includes reports to support analyses, such as contracting issues, clinical, ancillary or environmental trends, such as claim sales. review and confirm testing data for quality and accuracy.
  • Work with Excel Spreadsheets importing data from selected tables and exporting to spreadsheets and provides written and oral communications on generated reports via SharePoint in which the request was retrieved or PowerPoint via the client request.
  • Liaison between project managers, internal and external clients of variety analyses, to include, but not limited to, trend analysis, network evaluation, facility, ancillary contract evaluation, all claim data accuracy, staffing models and sales and enrollment.
  • Worked QuickBase tickets and other company systems for escalated issues to and provide root cause resolutions to system issues that’s driving incorrect outcomes for claims to process correctly.
  • Create meeting and attend calendar meetings for ad hoc meetings and with leadership provided a suggested streamlined process of improvement to internal and external partners to provide project updates and testing outcomes and the expectations of fixing the issue with a provided timeline.
  • Managed all travel bookings and reimbursement through Concur with the appropriate valid receipts.

Senior Provider Ancillary Advocate/Network Management

UnitedHealth Group
03.2016 - 08.2018
  • Build and maintain positive professional business relationships with all Providers, health plan contacts, ancillary providers and internal staff to work efficiently and effectively manage contracts for all of business, by initiating walk-in physician office visit, emails, via phone, and Web Ex meetings to solve more complex issues on Reimbursement policies, new provider contracts misinterpretations, Retro contract loads, and contract renewals.
  • Serve as a subject matter expert resource for Provider Advocates and Network Account Managers by using existing procedures and facts to solve routine problems or conduct routine analyses.
  • Analyze claims that were considered as a failure in UHC service model and provide root cause analysis of a claim issues, provide directives to adjusters for all lines of business in reprocessing claims that were inappropriately denied or requesting additional information on UNET, COSMOS, DIAMOND, and CSP Facets platform.
  • Coordinate with Internal Business Partners to resolve service issues such as: Claims Project Management, Contract Management system (CCI), Network Database, etc. and promptly escalate and initiate projects to be expedited for claim reconsideration of a Known Service issue, trends of claims processing issues, authorization denials, or any erroneous denials.
  • Provides education and resolution of findings to contracted providers, Provider Relations Reps and Network Management as needed.
  • Supported and participated in Service Model process and performance improvement activities to ensure our providers are excising the correct paths for reconsideration and appeal.
  • Sending updates through our internal process system with accurate information that resulted in resolutions of the provider’s expectations in a reasonable TAT for updates and follow-up responses to the providers.

Senior Recovery Resolution Analyst

UnitedHealth Group
05.2014 - 03.2016
  • Review claims pre-payment to validate the accuracy of the payment by examining Contracts attached to DRG’s, APCs, Fee for Service rates and document business operations and procedures to ensure data integrity, data security and process optimization with Investigation determination pursue recoveries and payables on subrogation claims, FWA Claims, and Flagged High Dollar claims.
  • Developed and maintained, positive professional business relationships with health plan contacts, ancillary providers, and internal staff to work efficiently and effectively managing all lines of business, while conducting Contract Audits on front end claims.
  • Compiled and analyzed data to identify the root cause analysis to provide feedback to internal partners, hospital and professional provider by conducting Web Ex meetings and conference calls to solve more complex issues on Reimbursement policies, new provider contracts misinterpretations, Retro contract loads, and contract renewals with CMS Medicare and Medicaid Billing payment rules.
  • Ensure to state and federal compliance policies, reimbursement policies, and contract compliance are being followed per High Dollar Claim by Utilizing knowledge and various resources related to payment rules, benefits, contracts (provider, state, CMS), pricing configuration, coding anomalies, authorization requirements, operational processes, and other factors that affect claim payment.
  • Effectively communicate any claim errors to the processor with directive on correcting the errors.

Provider Network Provider Relations Rep

United Healthcare
03.2012 - 04.2014
  • Serve as a subject matter expert resource for Provider Advocates and Network Account Managers by using existing procedures and facts to solve routine problems or conduct routine analyses.
  • Analyze claims that were considered as a failure in UHC service model and provide root cause analysis of a claim issues, provide directives to adjusters for all lines of business in reprocessing claims that were inappropriately denied or requesting additional information on UNET, COSMOS, DIAMOND, and CSP Facets platform.
  • Coordinate with Internal Business Partners to resolve service issues such as: Claims Project Management, Provider Appeal and Grievances, Contract Database, Roster Management and Network Data Management etc.
  • Managed all travel bookings and reimbursement through Concur with the appropriate valid receipts.
  • Managed escalations that were being transferred to our escalation team for resolution of denial errors, authorization denials, and any other erroneous denials of a Known Service issue and trends of claims processing issues.
  • Set up monthly meetings with providers via in- person or Webex to discuss the Data mining results and Ad- hoc analysis educating the providers as well as Provider Advocates and Network Management of my Final Resolution.
  • Supported and participate in Service Model process and performance improvement activities to ensure our providers are excising the correct paths for reconsideration and appeal.
  • Sending updates through our internal process system with accurate information that resulted in resolution of the provider’s expectations in a reasonable TAT for updates and follow-up responses to the providers.

Senior Recovery Resolution Analyst

UnitedHealth Group/Medicare and Retirement
09.2010 - 03.2012
  • Worked with Medicare and Retirement Recovery TRACR claims on overpayments for participating and non-Participating providers.
  • Retrieved issues via SharePoint through UHC internal partners and initiating recovery of overpayments with interest and clearing appropriate reviews.
  • Analyzed and identified trends of provider billing and claim processing that resulted in overpayments.
  • Initiating the recovery of overpayment through the tracer system with ensuring state and federal guidelines for reimbursement policies and contracts are complying and followed that may include interest.
  • Setting up ODAR request for providers within the Negative Payee Status in which we are unable to recover funds to the provider not having available funds and they are participating providers.
  • Working with Sam Edits approving and correcting claims in which has been processed in error based on all Edit rules.
  • Work efficiently in Provider and Member Service SharePoint, Subrogation, Fraud, Waste and Abuse ensuring all aspects of recovery is researched and done.
  • Initiating pricing through WEBSTRACT pricing for provider contract underpayment dispute.

Hospital Claim Analyst/Appeal and Grievance Specialist

AHC Convergent Inc. / Boca Raton, FL
09.2009 - 09.2010
  • Working with the account receivable department and customer service department of our client retrieving overpayments and adjusting underpaid Medicare, PPO and HMO claims.
  • Create offline appeal letters and explanation of benefits to our clients, reflecting claim adjustment processing and refunds.
  • Process third party billing of HCFA and UB92 claims, including coordination of benefits of Medicare, HMO, PPO and Medicaid benefits by paper for more complex claims and adjudication of claims.
  • Ensuring maximum expectation of reimbursement for the healthcare providers and ensuring billing is correct for proper processing of the claim. Utilizing my writing abilities, with representation of appeal letters, for all level of denials that will assure reprocessing of in appropriately denied claims were released for payment.
  • Working on the behalf of the hospital contacting Third Party payers for underpaid claims and posting payment from insurance companies and patients.
  • Analyzing claims and investigating the reason for underpayment and or the reason why the claim denied. Utilize my customer service skills by placing phone calls to insurance Managed care companies for payment pursuits
  • Generate appeal letters on behalf of the Hospital in argument and assurance that we are due additional money and demanding payment in full immediately especially for payment paid under the contracted amount.

Documentation Specialist/ Senior Customer Rep

OptumHealth /Lisle IL
04.2007 - 06.2008
  • Assisted Project manager with Overall Project Manager responsibilities for new business as a UAT tester and Post testing once the Employer’s business has went live for processing and Implementing plan system testing for new onboard Employer’s Group Plans, verifying Group coverages via IBAAG (Benefits Verification) used this system to verify readiness on going live for processing of new business.
  • Setting up electronic eligibility files for eligible transplant patients working closely with Case Managers, Account Managers, Benefit Configuration and Notification department
  • Keeping track of received data report and source documents, with detailed test status.
  • Enters alphabetic, numeric or symbolic data from source documents into a computer-based application (s, Facets following the format displayed on the screen. Ensure accuracy at all-time especially with Eligibility of clients, educate group plan account manager on reimbursement policies and drives adoption of self-service tools and provide support.

Client Service Associate/Claim Adjuster

Unicare Life and Health/Anthem, Chicago IL
10.1999 - 12.2005
  • Worked under limited supervision to resolve provider issues using independent judgments within guidelines., serves as the initial and main point of contact “Between” the Employer Company, Insures, current and potential members, beneficiaries, providers, employers, and agents in a Call center environment.
  • Answered provider calls in regard to Negative Balance Reports and claim issues. Mid -High Dollar claim audits for recovery on Hospital claim payment to release on claims processed by adjusters with dollar limitations.
  • Maintained Monthly Analysis of outstanding refunds to be posted within 14 days before another generated letter was sent to providers and members for overpayments.
  • Work with the accounts payable department (Claims Team) and customer service department of our client retrieving Overpayments and adjusting underpaid PPO and HMO claims. Process third party billing of HCFA and UB92 claims, including coordination of Medicare, HMO, PPO and Medicaid benefits by paper for more complex claims and adjudication EDI of claims.
  • Create offline letters and explanation of benefits to our clients, reflecting claim adjustment processing and refunds. Work on the designed Hanstar system using appropriate professional and hospital fees scheduling to claims. Maintained the Stop Pay Procedures Manual when appropriate, researched and resolved problems related to no match checks for the providers and applied refunds for overpayment to account that was overpaid to providers.
  • Provide timely and accurate resolution of inquiries analyzing issues regarding benefits provider contracts, pricing, processing issues of the member account, and responsible for achieving the goal of 20-second answer speed.
  • Resolve all Providers’ issues that were gathered on Physician and Hospital visit for reconsideration or possible appeal directives.

Education

High School Diploma -

Cornerstone Christian Corespondence School
Townsend
07.2003

Skills

  • Creative problem solver and very analytical team player who is successful in meeting deadlines, and handling pressure……at the same provide excellent customer service, reliable and adaptable; take initiative and readily to accept new responsibilities and challenges
  • Demonstrate attention to detail, strong organization skills, time management skills, strong analytical background, with strong presentation, great interpretation, writing and oral skills
  • Committed to quality and a high production work environment Maintained 998% accuracy based on the service observance performed
  • Expertise in Microsoft office products, Word, Outlook, Excel, Office XP, Microsoft Access, and PowerPoint Presentation
  • Experience with various Hospital Patient Access systems, Account Receivable systems, and EMR systems which includes IRMA, including correcting Quarterly AHCA reports, Safari and FACS for accounts receivable, ALLSCRIPTS, PBAR, MCKESSON, EPIC, MEDITECH, and Cerner
  • Experience in Analyzing pricing for approved fee schedule on adjudicated and non-adjudicated, paper claims for Manage Care medical claims,,disability claims, Rx Claims, HMO, PPO, and third-party claims, Medicare and Medicaid
  • Possess profound knowledge in ICD-9, ICD10 Diagnosis codes, Center of Medicare & Medicaid rules of MS-DRG, CPT and HCPCS codes Knowledge of pricing physician and outpatient fee schedule and Inpatient hospital claims with Webstract pricing, Encoder Pro for DRG, APC, and ASC pricing
  • Experienced in using Knowledge Library Reimbursement policy to provide education on ICES Edits claim denial, Claim-Xtend, DRG Outliers for inpatient claims, Sam Edits, TRACR, Fraud abuse and Subrogation
  • Provide excellent experience in different systems and applications to perform all job functions for, Third Party Insurance such as WellPoint, UNICARE, ANTHEM, AND UNITED Healthcare, CVS Aetna, Cigna Evernorth, and HCSC

Work Location

Remote

Timeline

Lead Quality Auditor Consultant

Cigna Evernorth Merged with HCSC
01.2025 - Current

Medical Claims Analyst

Aetna/CVS
01.2024 - Current

Senior Network Relations Analyst

Aetna/CVS
10.2021 - 04.2023

Grievance and Appeal Consultant

Aetna/CVS
07.2020 - 10.2021

Senior Reporting Analyst

United Healthcare
08.2018 - 12.2019

Senior Provider Ancillary Advocate/Network Management

UnitedHealth Group
03.2016 - 08.2018

Senior Recovery Resolution Analyst

UnitedHealth Group
05.2014 - 03.2016

Provider Network Provider Relations Rep

United Healthcare
03.2012 - 04.2014

Senior Recovery Resolution Analyst

UnitedHealth Group/Medicare and Retirement
09.2010 - 03.2012

Hospital Claim Analyst/Appeal and Grievance Specialist

AHC Convergent Inc. / Boca Raton, FL
09.2009 - 09.2010

Documentation Specialist/ Senior Customer Rep

OptumHealth /Lisle IL
04.2007 - 06.2008

Client Service Associate/Claim Adjuster

Unicare Life and Health/Anthem, Chicago IL
10.1999 - 12.2005

High School Diploma -

Cornerstone Christian Corespondence School

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