SU CHA
Altoona,WI
Summary
Business professional with comprehensive background in analyzing complex data to drive strategic initiatives. Known for enhancing operational efficiency and supporting decision-making processes through detailed analysis. Highly collaborative team member focused on achieving results and adapting to dynamic business needs. Proficient in data modeling and process improvement.
Overview
15
15
years of professional experience
1
1
Certification
Work History
Business Analyst I
Centene Corporation
10.2024 - Current
- Analyzed business requirements to enhance operational workflows and improve service delivery.
- Assess user requirements, processes, and issues to improve existing procedures
- Conduct comprehensive analysis on assigned projects and propose potential business solutions
- Collaborated with cross-functional teams to develop data-driven solutions for healthcare programs.
- Monitor and modify claims to ensure accuracy
Coding Analyst I
Centene Corporation
11.2022 - 10.2024
- High Dollar:
- Review High Dollar Physician and Hospital claims
- Review Provider contracts and ensure payment methodologies are applied correctly for reimbursement
- Assure manual calculations of provider contracts align with contractual requirements
- Identify system configuration issues and remediate with appropriate teams for resolution
- Attend meetings to discuss, resolve, and bring issues forward in team communication
- Transplant-High Dollar:
- Review High Dollar Physician and Hospital Transplant claims
- Identify trends and issues with system configuration
- Resolve Provider contract set-up with appropriate department managers
- Developed and refined coding standards to enhance data accuracy and efficiency.
- Analyzed complex data sets to identify trends and inform strategic decisions.
Health Information Management Specialist II
Marshfield Clinic Health System
03.2022 - 10.2022
- Index clinic and hospital documents into the electronic health record
- Index, legal, secure, and transferred records into the electronic health record
- Verifies scanned version is a high-quality electronic representation of original
- Completes rescans and versioning of documents
- Completes RightFax document indexing
- Correspondence with VA specialist on patient verification for quality assurance.
Claims Processor
Group Health Cooperative
04.2021 - 10.2021
- Process claims for payment assigned accounts from aged report, adjudication queue, and internal and external requests
- Assures claims are paid accordingly based on fee schedule, contract, group policy, and provider
- Review written correspondence and medical notes to assure claims are paid accurately
- Identify and communicate system issues, billing patterns, training opportunities with the claim supervisor
- Comply with company policies and procedures.
Senior Claims Business Process Consultant
UnitedHealthcare
08.2018 - 04.2021
- Louisiana State Encounters
- End-to-end research on Encounter bypasses and rejections by identifying root causes through data and process analysis
- Develop relationships with relevant stakeholders (e.g., health plans, state customers, etc.) to meet requirements and goals
- Conduct meetings to remediate conflicts and or inaccurate data within CSP Facets, configuration and or claims
- Perform intermediate level writing scripts in PL/SQL Oracle Database.
Sr Recovery Resolution Analyst
UnitedHealthcare
04.2014 - 08.2018
- Payment Integrity
- Managing and prioritizing claim audits; ensuring audits are within health plan performance target
- Identifying trends resulting in underpayment/overpayment
- Examine, assess, and document business operations and procedures to ensure data integrity, data security and process optimization
- Investigate research to find resolutions for all types of claims for health plans, commercial customers, and government entities
- Pursue recoveries with claims teams, payables on subrogation claims and file management
- Ensure audits are within state and federal compliance policies, reimbursement policies, and contract compliance
- Versed with multiple Health Plan markets for CSP Claims Platform, Diamond Claims Platform
- Finalize approval of High Dollar payment, within High Dollar threshold
- Complete second review on claims to ensure audit is completed accurately; payment $250k & greater
- Perform post ATA (audit the analyst) audits & ATA rebuttals on analysts on the team
- Provide coaching for analysts that are not meeting metrics & requiring additional support
- Communicate issues identified with PIPPA (Payment Integrity Prepay Audit) Managers for team coaching/development training
- Review, compile & prepare inventory reports for the team
- Process internal corrections for payment accuracy
- Escalate claim issues with stake holders for resolution
- Assist with new Health Plan migrations for the PIPPA (Payment Integrity Prepay Audit - High Dollar) Team
- Perform back-up Team Lead duties when necessary (inventory & escalated issues/inquiries)
- Perform back-up SME (Subject Matter Expert) duties for different Health Plan
- Review & assist with stake holders for standard operating procedure (SOP) & job-aid revisions
- Evaluate & answer questions on the Q/A SME SharePoint
- Performed administration duties by creating network user accounts, permissions, resetting passwords and administering group policies.
Subject Matter Expert
UnitedHealthcare
11.2012 - 04.2014
- Claims Operation
- Managing claim inventory levels by compiling daily reports, scrubbing aged claims, and identifying trends resulting in inventory increases
- Updating and creating documentation specific to State guidelines and contracts pertaining to payment or denial of claims
- Researching, identifying, and providing feedback and/or training to processors regarding incorrectly processed claims detected by Quality Assurance
- Conducting huddles and meetings relaying pertinent information to processors as needed
- Communicating with various departments within the company to ensure compliance in processing procedures
- Providing positive feedback and recognition to those surpassing daily expectations
- Preparing and performing training to processors regarding new claim processes and/or changes, Diamond cross training and state specific required items.
Claims Associate
UnitedHealthcare
08.2010 - 11.2012
- Claims Operation
- Reviewed specific holds populated on claims and determined appropriate action based on company specific processing instructions
- Identified trends in claim billing practices and reached out to management to resolve issues
- Met and exceeded production and quality expectations
- Reviewed and created Macro functions to simplify complex claim processes
- Assisted as an On the Job Trainer to load balancers and new hire classes
Education
Associate of Science - Health Information Management Technology
Chippewa Valley Technical College
Eau Claire05.2026
Medical Coder Diploma -
Chippewa Valley Technical College
Eau Claire, WI05.2025
GED -
Chippewa Valley Technical College
Eau Claire01.2013
Skills
- Strong interpersonal communication
- Optimization
- Quality Assurance
- Data recovery
- Process improvement
- Effective reporting capabilities
- Analytical
- Critical thinking
- Data analysis
- Microsoft Office Suite
- Project management
Certification
- Superior Health Plan - Lean Six Sigma White Belt Course 08/2024
- Superior Health Plan - Lean Six Sigma Yellow Belt Course 09/2024
Timeline
Business Analyst I
Centene Corporation
10.2024 - Current
Coding Analyst I
Centene Corporation
11.2022 - 10.2024
Health Information Management Specialist II
Marshfield Clinic Health System
03.2022 - 10.2022
Claims Processor
Group Health Cooperative
04.2021 - 10.2021
Senior Claims Business Process Consultant
UnitedHealthcare
08.2018 - 04.2021
Sr Recovery Resolution Analyst
UnitedHealthcare
04.2014 - 08.2018
Subject Matter Expert
UnitedHealthcare
11.2012 - 04.2014
Claims Associate
UnitedHealthcare
08.2010 - 11.2012
Associate of Science - Health Information Management Technology
Chippewa Valley Technical College
Medical Coder Diploma -
Chippewa Valley Technical College
GED -
Chippewa Valley Technical College
Similar Profiles
Leilani Ayers McMahanLeilani Ayers McMahan
Account Coordinator at Centene CorporationAccount Coordinator at Centene Corporation
Edgar SepulvedaEdgar Sepulveda
Manager of Intake Operations at Centene CorporationManager of Intake Operations at Centene Corporation
Winnie NyamapfumbaWinnie Nyamapfumba
Care Engagement Specialist at Centene CorporationCare Engagement Specialist at Centene Corporation
April PierceApril Pierce
Production Supervisor at Schuman CheeseProduction Supervisor at Schuman Cheese
Jaclyn LarsonJaclyn Larson
Stacks Maintenance Supervisor at University of Wisconsin Eau ClaireStacks Maintenance Supervisor at University of Wisconsin Eau Claire