Steve Rodriguez
San Antonio,TX
Summary
Detail-oriented with combined experience with Data Analysis, and Quality Assurance Specialist with over 15 years of experience in Quality Monitoring, Data Analytics, and Auditing, along with 5 years as a Contract Analyst specializing in Facility GPO Contracts, Non-Contracted Facilities, and Customer Pricing. Demonstrates exceptional communication, organizational, and time management skills. Experience with data analysis and business intelligence tools that facilitate the identification of trends and delivery of actionable insights that drive informed business decisions.
Overview
16
16
years of professional experience
Work History
Payer Relations Analyst
Solventum
09.2023 - Current
- Payor Relations Analyst are involved in the coordination and partnerships between Solventum, healthcare providers, and insurance companies.
- Ensure health insurance requirements and correct reimbursement is accurately applied as this affects the financial health of Solventum by streamlining reimbursement processes for financial stability and efficiency which will result to better cash flow and patient care.
- Collaborate with multiple teams (such as Strategic Growth MCO Contracting Team, MCO Account Managers / Sales / Field, National Call Center, Order Fulfillment, Billing Verification, Homecare Collections, Claims Presentation (Billing)/ EDI, QA, and Legal/ Compliance) so our systems have to most accurate healthcare requirements to create efficient workflow and reduce/resolve aged AR.
- We are the liaison between payors and Solventum/KCI by maintaining an in depth understanding of the Payors and Solventum’s operations to secure payment for services rendered.
- Ensures that the Payor Rules, Policies and guidelines are followed and that operations run smoothly. Also, we administer payer rules and entries across various systems that drive the Order to Cash outcome.
- Monitors payor behavior and payor communications to identify any process changes that may impact cash flow. Examining claims data is essential for understanding reimbursement patterns and identifying trends within the payor system. Analyzing Unbilled and Billed Revenue and all components of Account Receivable and reimbursement helps optimize financial outcome and improve internal and external processes.
- Work in Payor Knowledge, HERO, Oracle, Delair, CFF, Filenet, SSI Click On, TAbleau, JIRA, and Business Objects. Work ticket request to update Payor Knowledge entries, update Payor processes and document payor policies PRAs manage information. Submission of Delair Billing Rules or Billing Rule submission from other teams that require approval via BIT via Jira.
- Analyze, Find RCA, and resolution for Collections AR Issues triggered by internal or external factors via Payor Issue Tracker (PIT) in Jira.
- Also involve with various applications that involve Claim Form Fax, Newsletter from Payers, Payor Audits, Customer 1st, and Emails/Calls/ Projects, Meetings and MS Teams.
Senior Appeals Specialist
3M
05.2022 - Current
- Maintained strong knowledge of basic medical terminology to better understand services and procedures.
- Prepare and present patient testimony to ensure all medical record evidence is accurate and meets Medicare LCD Medical Criteria. Participate as a testifier appearing before an Administrative Law Judge with DLA Piper Law Firm as KCI counsel.
- Communicate and work with DLA Piper Law Firm who is from Washington DC on which cases will be pursued at hearing as well as cases that will need to be withdrawn at hearing. The pursued cases are strong medical evidence that meet Medicare Coverage Criteria and addresses the Qualified Independent Contractor's denial in order to obtain a favorable judge ruling for payment of the denied claims.
Sr. Quality Specialist
3M
03.2022 - 05.2022
- Provided regular updates to team leadership on quality metrics by communicating consistency problems or production deficiencies.
- Collaborated with management to provide training on improved processes and assisted with creation and maintenance of quality training.
- Collected and analyzed activity data and initiated, developed and recommended improvements to systems, processes and procedures to increase productivity and reduce cost.
- Developed monthly, end-of-quarter and other statistical reports for leadership team and quality improvement programs.
- Provided analytical, planning and coordination support on projects as assigned, reviewing, interpreting, analyzing and illustrating data to stimulate and support enlightened decision making.
Quality Specialist
3M
01.2015 - 04.2022
- CMS Audit Reviews
- Conduct quality reviews on the PRA Team's data entries in Oracle and Master File, which is data published by CMS consisting of Fee Schedules and/or Zip Code updates on a quarterly bases (or anytime CMS publishes new/revised updates).
- The length of reviews are based on the volume of updates provided by CMS which could take 1-2weeks (could be longer). Utilize Excel, Oracle and Share Drives conduct reviews and archive data.
- After an Initial Sweep, I will communicate discrepancies found (or not) directly to the CA so correction can be applied to the system impacted or once review is finalized. A Final Sweep is conducted (if necessary) for the CA corrections addressing the Initial Sweep which is the final action for QA.
- Paid Claim Reviews
- Complete monthly Paid Claim reviews for the following business categories: MCO_MCR_MCD (115), Charity Care(10) and High Cycle-MCO_MCR_MCD (10). Communicate Critical Errors (while conducting monthly reviews) to the business for possible corrective actions.
- Conduct a total# of 405 reviews per quarter. Utilizing Verint-Quality Monitoring system as the QA platform (questions classified as Critical and Non-Critical), referencing business SOPs/PORT/Payor Tool/PIP as resources and use of various application (i.e. Oracle, Delair, HERO, etc.)
- Analyze/Report monthly data and create PPT Deck to present quarterly results to our Senior Leadership, Compliance Dept and Legal. As well as provide Action Plan(s) for question(s) that did not meet Target Performance Goals.
- Verint Reporting
- CDT Report (Monthly/Weekly)
- Provide assistance to the CDT Team with the building/development/design /maintenance of the Verint-Quality Monitoring Forms utilized for their own internal quality reviews which are performed by their own leadership.
- Provide assistance to the CDT Team with the building/development/design /maintenance of the Verint-QM Reporting which consists of Dept/Team/CSR performance levels monthly (includes weekly data results) used for CSR merit score cards.
- Customer First Report (Monthly)
- Compile various tableau reports from various targeted businesses each month that contain Transactional Orders compared with the Customer First Tracking Ticket occurrences associated to that targeted business that analyzes the % CF of Order Volume.
- Utilize control charts formulas to determine the % CF of Order Volume and communicate monthly results to business leaders outlining the % CF of Order Volume activity providing the UCL and LCL controls. Provide business explanations based on the data behavior in comparison to prior month in the event percentage is above or below average.
- Report monthly to business leaders via PPT Deck for each targeted business.
- Plan to begin training Jennifer Carreon to CF reporting process to assist with this process on end of April 2021.
- Paid Claim
- Build/development/design/maintenance of the Verint-Quality Monitoring Forms for this QA function.
- Build/development/design/maintenance of the Verint-QM Reporting for this QA function.
- Pricing/Contracts
- Build/development/design/maintenance of the Verint-Quality Monitoring Forms for this QA function.
- Build/development/design/maintenance of the Verint-QM Reporting for this QA function.
- NICE In Contact QA Management
- Received classroom training on the following QM functions: Creating QM Forms and Reporting. The utilization of this application will be determined by manager.
Contract Specialist
KCI-Acelity
01.2010 - 12.2015
- Created new facility accounts as well as updated existing facility accounts in Oracle upon receipt of requested by either internal or external customers via Hero Support Log.
- Owned and managed highest revenue GPO (Group Purchasing Organization) Novation. Updated 7 Tiered contracted pricing in Oracle based on new Novation members and aggregated GPOs. Also, updated local contracts, multi-contracts and discount programs per request by CCG (Customer Contracts Group).
Education
No Degree - Machinist
United States Navy
San Diego, CA08.1998
Associate of Science - Business Administration And Management
Palo Alto College
San Antonio, TX08.2005
High School Diploma - undefined
South San High School
San Antonio, TX08.1994
Skills
- Team Collaboration
- Customer Service
- Project Management
- Data Analysis
- Performance Monitoring
- Correction Action Planning
- Corrective Actions
- Team Leadership
- Analytical Thinking
- Internal Audits
- ALJ Appeal Testimony Writer
- Microsoft office
- Analytical thinking
- MS Excel
- Time management
- Team collaboration and leadership
- Attention to detail
- Critical thinking
- Decision-making
- Analytical problem solving
ADDITIONAL INFORMATION
- Applications:
- Oracle
- HERO
- Tableau
- Delair
- PORT/PIP/Payor Tool
- Business Objects
- Excel (Control Charts/Pivot Tables/Graph Charts)
- Word
- Outlook
- Power Point
- MS Teams
- Emptoris
- Verint (and Form Designer)
- Nice in Contact
- TapRoot
Timeline
Payer Relations Analyst
Solventum
09.2023 - Current
Senior Appeals Specialist
3M
05.2022 - Current
Sr. Quality Specialist
3M
03.2022 - 05.2022
Quality Specialist
3M
01.2015 - 04.2022
Contract Specialist
KCI-Acelity
01.2010 - 12.2015
Associate of Science - Business Administration And Management
Palo Alto College
High School Diploma - undefined
South San High School
No Degree - Machinist
United States Navy