Susanna Haros

• Responsible for translating benefit policies to ensure that policies are designed and configured appropriately in KP system in order to ensure that assignment to industry standard codes (CPT, HCPCs, ICD-10) thus enabling appropriate billing and claims adjudication and receipt of accurate member cost-share at point of service.
• Responsible for on-going code maintenance, e.g., quarterly and annual code updates.
• Partner with Regulatory, Medical Group Operations, Actuarial, BIC, Revenue Cycle, Benefits Administration, and benefit policy to gain approval of BCIFs and CRs and support benefit coding.
• Play a pivotal role as the subject matter expert in conducting comprehensive analysis for California into actionable code mapping recommendations.
• Responds to and resolves in a timely manner production issues related to coding issues and ad-hoc releases.
• Utilizing and reviewing all applicable documents, including but not limited to Benefit Mapping Source Document (BMSD), National Preventive Code Set (NPCS), and benefit coding process materials.
• Prepare governance materials for decision making bodies as assigned.
• Manage items in the benefit coding pipeline and participate in coding review meetings.
• Manage digital content (Info Source, BMSD, NPCS). Complete an annual/bi-annual review of digital content for assigned areas of responsibility to maintain accuracy and relevance (i.e. Diagnosis Code Sets, process documents, etc.).
• Partner with respective stakeholders to resolve benefit testing defects, coding anomalies/inconsistencies, claim holds (e.g., BEH03), and utilizing the California Claim Issue Tracker (CCIT).
• Review and identify gaps and necessary changes needed to meet the intent of the federal/state mandates, regulator directives, or business initiatives described in the BCIF.
• Testing Lead - Collaborate with Policy, Configuration, and Testing teams (BQA) to prioritize defect issues, document the prioritized defects in the defect log, and update the resource tool. Ensure that accurate tracking and resolution of defects with continuous process improvement to minimize similar testing defects in the future, enhancing overall quality and performance.
• Train and support new Consultants.

Kaiser Permanente: (Randstad Technologies Staffing August 2019 - April 2020)

• Audit and ensure correct configuration and mapping of benefits within Benefit Enhancement Tracking System (BETS) for the National Benefit Administration supporting the Georgia & MAS Regions.
• Quarterly medical codes validation in BETS.
• Conducted validation with various source of truth documents under the Georgia & MAS Benefit Policy Administration (Plan Design Grid) to validate benefits (co-pay, cost share, accumulation, MOOP, deductible, etc.)
• Extensive experience validating across different Lines of Business and various product types (National, Multi State, Private Exchange, Kaiser Groups, Self-Funded, Medicare, Medi-Cal, Senior Advantage, KPIF, KPMP, KYP, KP Plus, Level Funded, Standard Plans, Custom Plans, Small and Mid-Large Health Plans, HMO, DHMO, PPO, HDHP, HSA, Added Choice, OOA, Virtual Plans).
• Supported successful completion of Open Enrollment for both MAS & GA regions continuously for three years.
• Making sure that all policy documents are compliant and up to date when validating benefits & plans.
• Utilize BIT (Bizagi), EMWS (Enterprise Membership Workflow System), MACESS/RCS (Rate Calculation Sheet), MVP Tool (Coverage Set query tool), AD HOC Reporting (Alternate to MVP query tool), CBVP (Coverage Set & Benefit master query tool), CTC (Coverage Set ID Compare Tool), KPSC (KP Sales Connect), CM (Common Membership), KPHC (KP Health Connect), TMS (validation of array codes), KPBC (KP Benefit Connect) and Plan & Benefit Validation Automation Tool to conduct validation for the Mid to Large Lines of Business.
• Testing & analyzing new validation automation tool and recommend process improvements to management to create an innovative business solution.
• Experience with Benefit Configuration Forms and Rate Calculation Sheets.
• Working with internal departments such as Plan Architects & BEA's to validate and close cases.
• Making sure benefits are mapped correctly and compliant to ensure reliable reporting.
• Formatting and working with Excel spreadsheets on a daily basis.
• Identify and triage problems and effectively communicate those problems to the appropriate resources and recommend remediation.
• Demonstrating the knowledge, skills, abilities, and behaviors necessary to provide superior and culturally sensitive service to each other and to our members, also to our internal & external customers.
• Trained in California testing process and related documents (BCIF/Benefit Change Intake Form, CWS/Coding Work Sheet, BMSD/Benefit Mapping Source Document).
• Randstad Technologies Staffing

QTC Management Inc: (LANI Staffing Agency April 2017 - October 2017)

• Performs coding and documentation review of records to ensure company billing policies and procedures, contractual requirements and government (VA) billing regulations.
• Claims processing and billing.
• Making sure that codes are updated (CPT, ICD-10, HCPCS).
• Perform Analysis with documentation of policies, practices and processes, methods, and solutions ranging from moderate to complex.
• Utilizing data analysis and extraction tools to evaluate billing transactions and identify potential billing errors.
• Identify and research audit findings presenting concerns and solutions to appropriate leadership.
• Responsible for ensuring data integrity within the system for VA providers.
• Assists in setting standard of quality, suggests improvements oriented to continued improvement and able to provide a synopsis of findings.
• Complete most routine audit functions with minimal supervision.
• Perform multiple quality audit transactions, projects, and duties assigned bringing them to completion by deadline.
• Delivering high quality results on time.
• Superior communication, conflict management, and problem resolutions.
• LANI Staffing Agency

• Supervise employees in making sure work schedules are maintained, train employees and oversee patients' appointments.
• Responsible in making sure all guidelines and company policies are adhered to.
• Coding diagnosis to prepare for billing using daily superbills.
• Processing claims, billing, collections, updating all medical records.
• Acts as a communication liaison between the office and direct reports and outside clients.
• Admitting patients and interacting with skilled nurses and case managing nurses.
• Processing all workers compensation paperwork/billing and working with case management, referrals, pharmacy requests.
• Making sure Doctors' credentials are up to date and compliant with professional standards with State and Federal Laws and contract requirements are met.
• Oversee and administer daily deposits and office budget.
• Work with HR Consultants to facilitate resolution of any problems.
• Provide patients with billing information in case of invalid insurance.
• Assess staff performance and ensure that performance constantly meet expectations and standards, manage performance reviews.
• Process payroll for medical staff.
• Educate patients about medical procedures and assist doctors with conducting processes.
• Ensuring a safe environment (OSHA) for employees and patients as well as handling conflicts and concerns in a diplomatic manner.

• Under VHA managed staff of 5 sales representatives, hired, trained, supervised day-to-day sales productivity and lead projects with regional and national programs.
• Coordinating and planning analysis of client business processes and functional requirements and preparing appropriate documentation to communicate and validate the information.
• Provide leadership and facilitation in the resolution of highly strategic and sensitive issues and projects of regional, statewide, cross-entity or cross-functional and reports directly to the leadership department.
• Prepare and process recommendation documents, including presentations, process maps, business requirements and related impact analyses.
• Work with reporting requirements, report development, and reporting tools (SQL Query).
• Collects and researches specific client requirements for projects, identifies requirements, gathers workflow data and basic system and reporting specifications.
• Account Managing, creating relationships with assigned customers/internal clients.
• Increased market share by 50%.
• Travel to assigned territories once every 3 months.