Tasheè Coles
Summary
Driven professional with competency in project development, business requirements gathering, business analysis, project management, application development and system implementations. Dedicated team leader with the ability to effectively manage and achieve project goal, leveraging my complex understanding of claims processing and systems engineering concepts. Proven success in meeting new challenges and finding effective solutions.
Overview
15
15
years of professional experience
Work History
Principle Business Analyst, Claims Resolution
Jefferson Health Plans
Philadelphia, PA
01.2022 - Current
- Acts as a SME for HRP functionality
- Expert on user acceptance testing, end-user training, business/systems requirements and configuration
- Active research, investigation and resolution of claims processing trends identified during monthly Revenue Cycles and system monitoring
- Investigated and addressed system issues to enhance usability and improve functionality.
- Oversaw integration of software programs and system upgrades: 3M, ClaimsXten Select and Zelis
- Organized system infrastructure documentation and operating procedures, strengthening controls and enhancing overall performance.
- Developed SOPs for stakeholders to allow for the ability to efficiently utilize their business analysis platforms and make appropriate sound decisions.
- Applied knowledge of data modeling and statistical analysis to note trends and draw conclusions.
- Worked on 835 transaction claims payment and remittance advice to ensure proper payment detail from payer to provider
- Actively participated in the successful integration and monitored 837 transactions into source system
- Collaborated closely with executive level leadership to drive strategy through development and implementation of new processes.
- Managed the execution of user simulation software and systematic claims reprocessing program to conduct mass updates of claims
- Knowledge of financial credit balance, check cycle and payable/receivable interactions within the HRP user interface
- Enhanced interfaces to promote better functionality for users.
- Investigated system issues and implemented resolutions to reduce downtime.
- Performed system analysis, documentation, testing, implementation, and user support for platform transitions.
- Works with other analysts and technical teams to create detailed functional requirements and testing scenarios
- Fostered culture of continuous improvement by leading regular review sessions to identify and implement process enhancements.
- Generated ad-hoc reports to evaluate specific business requirements.
- Utilized corporation and developed Agile methodology
Senior Business Analyst Claims
Health Partners Plans
Philadelphia, PA
07.2017 - 01.2022
- Claims and Operations lead for HRP "Health Rules Payor" Manager and Designer implementation
- Supported ongoing operation o transactional systems
- Developed test strategies and test plans for EDI 837/ 835 files during system implementation
- Implementation lead for HealthCare Management system, including CCMS and HRCM
- Implementation lead for cost saving external AMA/CMS editing vendors 3M,
- Lead for CCE and ClaimsXTen implementation
- Extensive knowledge of CMS/State driven claims processing for Medicare/Medicaid/CHIP business
- Work closely with outside area to understand business issues and coordinate resolutions through documenting workflows or extracting reports to satisfy the business requirements
- Creation and execution of user keystroke duplication software scripts (Nintex) to increase productivity
- Responsible for script creation for HRP specific auto processing and loader tool
- Synthesized current business intelligence data to produce reports and polished presentations, highlighting findings and recommending changes
- Interacted with internal customers to understand business needs and translate into requirements and project scope
- Established documentation framework to support Agile methodology implementation
- Supported leadership team with reporting, analysis and business presentations to inform divisional strategies.
Vendor Specialist
Health Partners Plans
Philadelphia, PA
07.2014 - 02.2017
- Identified cost-effective vendors and set up favorable contracts, saving $4.3 million per year in Claims overpayment and commission fees.
- Coached staff on daily performance and conducted evaluations to constructively address concerns
- Tracked and analyzed reports to determine needed improvements
- Provided reporting for monthly forecast analysis and ad-hoc reporting in support of decision-making
- Developed and updated tracking spreadsheets using Excel and Access
- Completed annual reviews of vendor policies and procedures
- Organized and maintained vendor records in accordance with corporate guidelines.
Claims Examiner
Health Partners Plans
Philadelphia, PA
04.2012 - 06.2014
- Examined claims forms and other records to determine insurance coverage
- Reviewed and analyzed suspicious and potentially fraudulent insurance claims
- Worked with other claims adjusters and examiners to expedite processing in alignment with procedures
- Evaluated accuracy and quality of data entered into Claims management system
Lead Claims Processor
Card, Blue Cross and Blue Shield
07.2009 - 06.2012
- Managed ITS Host and Blue card business which included daily large volume medical claim review and processing
- Evaluated accuracy and quality of data entered into Claims management system
- Maintained knowledge of benefits claim processing, claims principles, medical terminology and procedures and HIPAA regulations
- Reviewed provider coding information to report services and verify correctness
- Calculated adjustments, premiums, and refunds.
- Evaluated accuracy and quality of data entered into agency management system.
Education
Bachelor of Arts - Business Administration
Temple University
Philadelphia, PA05.2012
Skills
- System Implementation Lead
- Extensive knowledge of CMS/State driven claims processing for Medicare/Medicaid/CHIP business
- Business Process Analysis
- Process Improvement
- Business Product Development
- HealthRules Payor Configuration
- User Acceptance Testing (UAT)
- Technical Integration
- Experience developing Business Requirements Documents (BRDs)
- Atlassian JIRA knowledge
- Agile Principles/Methodologies
- Infrastructure Solutions
- Effective leadership
- Interpersonal Skills
- Cross Functional Team Leadership
- Microsoft Office Suite
- Scrum Methodology
- Project Management
Timeline
Principle Business Analyst, Claims Resolution
Jefferson Health Plans
01.2022 - Current
Senior Business Analyst Claims
Health Partners Plans
07.2017 - 01.2022
Vendor Specialist
Health Partners Plans
07.2014 - 02.2017
Claims Examiner
Health Partners Plans
04.2012 - 06.2014
Lead Claims Processor
Card, Blue Cross and Blue Shield
07.2009 - 06.2012
Bachelor of Arts - Business Administration
Temple University