Tawanna Ramirez
Fairfield,CA
Summary
As the CEO and CAO of Sociotechnical Healthcare Solutions, interest in the automation of the BIR side of the American Healthcare system led to the creation of the firm. This resume lists projects in which I've worked. I have facilitated a range of clients from start-ups to well established fortune 500 companies. I have established each client with a track to success and each client I have worked with experienced exponential revenue increases.
I am an Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals.
Overview
12
12
years of professional experience
Work History
Senior Business Systems Analyst
Interbase
Santa Clara, CA
10.2021 - Current
- Trained business personnel in use of systems.
- Monitored employee tasks to gauge business functions and inefficiencies.
- Created and maintained standard operating procedures governing system functions and features. Including, but not limited to: training material, training sessions and review process SOP/DLP.
- Improved systems with addition of new features and infrastructure.
- Tracked feedback at all levels and researched resolutions for common concerns.
- Identified needed business improvements and determined appropriate systems required to implement solutions.
- Collected, defined and analyzed business requirements.
- Consolidated business rules for system enhancements.
- Installed system updates to address vulnerabilities and reduce security issues.
- Manage 837 files, 835 files, 277CA and 999 files
- Perform User Acceptance Testing (UAT testing)
- Identify configuration and mapping errors.
- Applied appropriate data science techniques to solve business problems.
Business Systems Analyst
TEKsystems
Nashville, TN
09.2020 - 10.2021
- Translate Business requirement document to build MC400 case rate model
- Create test files (mock 837) conduct UAT testing, perform QA on system builds (mock 835)
- Configuration was done on back end of system through Microsoft Access
- Collected, defined and analyzed business requirements.
- Configure claims adjudication system to ensure proper 835 output (MC400)
- Took notes during meetings to better understand project initiatives and to distribute to stakeholders.
- Maintained knowledge of benefits claim processing, claims principles, medical terminology, and procedures and HIPAA regulations.
Revenue Cycle Analyst
John Muir Health
Concord, CA
01.2020 - 09.2020
- Research and resolve incorrect payments, EOB rejections, and other issues with outstanding accounts.
- Track denials/system issues; escalate for resolution.
- Communicated revenue cycle information to non-technical audiences in easily understood terms.
- Perform revenue cycle analysis for denied payments: create denial tracking and follow up on Insurance denials from 835 files.
- Tracked and reported variances between revenue plans and actuals.
- Resubmitted claims after editing or denial to achieve financial targets and reduce outstanding debt.
- Re-submit insurance claims as necessary via 837 submissions.
- Generated receivables report and offer improvement recommendations.
- Compose technical appeals/contract disputes based on CMS guidelines.
- RCM analysis: Perform expected reimbursement analysis based on EPIC calculation and manual pricing of inpatient claims via APR-DRG Pricer, price outpatient claims using CMS guidelines, APC pricing methodology.
- Selected as Subject Matter Expert to participate in claims redesign system.
Coding and Compliance Analyst
Cogitativo
Berkeley, CA
05.2018 - 01.2020
- Assist in build of algorithms for cost avoidance software for health insurance companies, perform UAT testing Tapestry, Facets, QNXT, MC400, Diamond
- Monitored resolution of bugs, tested fixes and helped developers tackle ongoing problems by providing QA perspective.
- Incorporated delivery requirements into planning of testing schedules.
- Tested functional and compatibility of new programs or updates in comparison to existing applications.
- Reviewed all appeal types (coding, contractual etc.), researched regulatory and compliance g/l, and created coding rules for our data scientist to build new algorithms based on CMS guidelines.
- Review data from 837 and 835 to perform analysis and claims submitted, expected reimbursements and actual reimbursements.
- Maintained knowledge of CPT, HCPC, ICD-10, NCCI guidelines
- Examined reports, accounts, and evidence to determine integrity and accuracy of information.
- Pinpointed meaningful insights from large data and metadata sources.
- Identified, analyzed and interpreted trends in complex data sets using supervised and unsupervised learning techniques.
Claims Analyst
Hill Physicians Medical Group
San Ramon, CA
02.2017 - 05.2018
- Review 837 data: review claim edits, adjudicate according to HPMG guidelines and DOFR
- Tier 1 technical QNXT training
- Conducted day-to-day administrative tasks to maintain information files and process paperwork.
Senior Reimbursement Specialist
Diablo Valley Oncology
Pleasant Hill, CA
09.2014 - 02.2017
- Manage all PPO, Medi-Cal (traditional Medi-Cal) and Medi-Cal managed plan accounts (Medi-Cal HMO)
- Research and resolve incorrect payments, EOB rejections, and other issues with outstanding accounts based on 835 information
- Verify correct ICD-10 and CPT codes
- Composed insurance claim appeals with supporting related documents.
- Resubmitted claims and 837 files after editing or denial to achieve financial targets and reduce outstanding debt.
- Communicated with insurance companies to research and resolved coding discrepancies.
Claims Analyst
Partnership Healthplan Of CA
Fairfield, CA
08.2013 - 09.2014
- Adjudicate: UB04 and CMS 1500: LTC, outpatient and inpatient claims
- Calculate and price inpatient claims per APR-DRG guidelines.
- Work within claims management system with output of 835 files
- Increased claims processed for insurance payments and/or denials.
- Maintained accurate documentation of payments.
- Slashed processing time and assisted in automation for tier I analytics.
Medical Billing Manager
Marin Medical Practice Concepts
Fairfield, CA
08.2011 - 08.2013
- Medical billing submits 837 files to insurance payors, perform analysis and follow-up from 835 files.
- Post payments and EOB denials from 835 file and EFTs received from clearinghouse.
- Compose appeals, Dispute claim denials.
- Research and resolve incorrect payments EOB rejections and other issues with outstanding accounts.
- Create financial dashboards to provide insight into key performance indicators.
Education
No Degree - Data Science
Massachusetts Institute of Technology
Cambridge, MA2023
Master of Science - Healthcare Administration
California State University - East Bay
Hayward, CA2022
Bachelor of Arts - Sociology
California State University - East Bay
Hayward, CA05.2019
Skills
- Software Applications: EPIC, Tapestry, QNXT, TriZetto, Amysis, MC400, AS400, Diamond, Facets, OPTUM, Advanced Md, Allscripts, Claims GUI, DDE (Medicare) Microsoft Office systems (Word, Excel, Office)Access, JIRA, Confluence, SQL, IBM I- Navigator, MCNET, MyAvatar (Netsmart)
- Python, SQL, Excel
- Data Analysis
- User Acceptance Testing (UAT)
- Technical Assessment
- Test and Optimize Systems
- Business Documentation
- Workflow Analysis
- Medical Terminology
- CPT Code Modifiers
- Coding Appeals
- Medical Claims Coding
- ICD-10 (International Classification of Disease Systems)
- Variance Reviewing
- ICD-10 Requirements
- Paperwork and Documentation
- Insurance Claims Analysis
- Compliance Requirements
- Electronic Medical Record (EMR) Systems
- HIPAA Requirements
Timeline
Senior Business Systems Analyst
Interbase
10.2021 - Current
Business Systems Analyst
TEKsystems
09.2020 - 10.2021
Revenue Cycle Analyst
John Muir Health
01.2020 - 09.2020
Coding and Compliance Analyst
Cogitativo
05.2018 - 01.2020
Claims Analyst
Hill Physicians Medical Group
02.2017 - 05.2018
Senior Reimbursement Specialist
Diablo Valley Oncology
09.2014 - 02.2017
Claims Analyst
Partnership Healthplan Of CA
08.2013 - 09.2014
Medical Billing Manager
Marin Medical Practice Concepts
08.2011 - 08.2013
No Degree - Data Science
Massachusetts Institute of Technology
Master of Science - Healthcare Administration
California State University - East Bay
Bachelor of Arts - Sociology
California State University - East Bay
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