Teri E Swanson

• Applies a comprehensive knowledge of claims processing, provider contracts and contract configuration to escalated provider inquires.
• Support business initiatives through data analysis, identification of implementation barriers
• Identify and analyze, procedures, and problems to improve existing processes
• Perform detailed analysis on assigned projects, recommend potential business solutions, and assist with implementation
• Lead problem solving and coordination efforts between various business units
• Assist with formulating and updating departmental policies and procedures
• Performs other projects as assigned
• Interacted with internal customers to understand business needs and translate into requirements and project scope.
• Boosted customer satisfaction levels by identifying areas of improvement and proposing actionable solutions.
• Enhanced company-wide decision-making by developing comprehensive reports on key performance indicators.
• Analyzed data to identify root causes of problems and recommend corrective actions.
• Actively participated in team meetings to share knowledge, exchange ideas, address challenges, and collaborate on potential solutions.
• Developed high-quality documentation to support training efforts, helping employees fully understand new systems and procedures.
• Performed gap analysis between existing systems or processes and desired state, identifying areas for improvement or enhancement.

Serves as a mentor for all Claims Audit Specialists (lead 10) and provides real-time feedback for the job function.

• Serves as a SME and Lead Auditor.
• Performs peer reviews of audit staff and reviews scores with supervisor/manager and recommends process improvement as needed.
• Works with management to maintain a well-trained work force in the department to ensure a high-quality control program.
• Researches and proposes solutions for escalated issues in a clear and concise manner.
• Assists with developing and maintaining departmental policies and procedures including desk top procedures.
• Leads in developing training materials for the department and facilitates training as needed.
• Analyzes errors and performs root cause analysis to determine appropriate classification.
• Builds and maintains positive business relationships with business partners.
• Conducts claim audits in a lead role for internal and external entities.
• Communicates audit results in a structured format.
• Assists with identification and communication of process improvement opportunities across operation area's based on quality reviews.
• Performs additional duties as assigned. i.e., Release high dollar claim audits & distribute workload.
• Managed a high volume of claims effectively by prioritizing tasks and maintaining excellent organizational skills.
• Enhanced customer satisfaction with timely communication, empathy, and clear explanations of claim outcomes.
• Collaborated with cross-functional teams to optimize claims handling procedures, resulting in improved productivity.
• Reduced claim processing errors by conducting thorough investigations and accurately interpreting policy details.
• Enhanced customer trust and satisfaction by efficiently resolving claims disputes.
• Conducted regular audits of claim files, ensuring compliance with internal and external regulations and standards.
• Improved team morale and productivity by fostering collaborative work environment.
• Worked with claims adjusters and examiners to expedite processing in alignment with procedures.
• Resubmitted claims after editing or denial to achieve financial targets and reduce outstanding debt.
• Modified, updated and processed existing policies.
• Trained new team members by relaying information on company procedures and safety requirements.
• Promoted a positive work environment by fostering teamwork, open communication, and employee recognition initiatives.
• Coached team members in techniques necessary to complete job tasks.
• Enhanced overall team performance by providing regular coaching, feedback, and skill development opportunities.
• Established open and professional relationships with team members to achieve quick resolutions for various issues.

• Research State and Federal mandates resulting in policies and procedures.
• Ensures proper supporting documentation and maintains files for all price rules fee schedules.
• Research and resolve complex claim issues in a timely manner while consistently exceeding the quality standard.
• Builds and maintains positive business relationships with business partners.
• Build and maintain Default/Custom Medicare and Medicaid Fee Schedules.
• Responsible for training on Sox Audits and FMT
• Responsible for updating Discount/Sequestration, Interest and Max Units
• Working with databases and automating daily routines.
• Monitoring and updating BDD Compliance 360
• Ability to communicate and make recommendations to upper management.
• Ability to work independently.
• Ability to meet deadlines and turnaround
• Responsible for Anesthesia Conversion Factors and Base Units
• Received Awards Everyday Reward from my current manager for my sense of urgency and commitment to getting the job done correctly and timely.
• Received Operations Account Team (OAR) MVP for January Partnership and OneTeam approach.
• Received Award Everyday Reward from the Ancillary Management for partnership and loading of contract correctly and helping with claim issue.
• Supported customers and government teams with accurate, timely information on infrastructure system and service configuration items.
• Implemented change control, configuration status accounting and configuration audits.
• Trained junior team members on best practices in configuration management, improving overall team productivity and expertise.

• Builds rules within the Xcelys System, in coordination within State and Federal guidelines.
• Research State and Federal mandates resulting in policies and procedures.
• Ensures proper supporting documentation and maintains files for all price rules.
• Builds and maintains positive business relationships with business partners.
• Assist in the development of reporting to provide visibility to key business metrics.
• Working with databases and automating daily routines.
• Monitoring and reviewing quality reports.
• Ability to communicate and make recommendations to upper management.
• Ability to work independently.
• Respond timely to emails with professional analytics, timely is considered 1 business day
• Use all Resources; Xycels, Omni Flow, emails, critical thinking methods, etc., & then consult with your leader for guidance if necessary.
• Pull & Distribute Daily Reporting.
• Prioritize daily inventory assignments
• Attend meetings.
• Keep leadership team engaged on matters concerning the Market.
• Contribute to maintaining a positive team environment.
• Developed comprehensive documentation for all configuration processes, facilitating knowledge sharing among team members.
• Established a culture of continuous improvement within the configuration management team by regularly reviewing processes and implementing new best practices as needed.
• Conducted root cause analyses of configuration issues, identifying areas for improvement and implementing corrective actions accordingly.
• Improved configuration processes by streamlining workflows and implementing automation tools.
• Provided timely support for end-users, resolving configuration-related issues quickly and effectively.
• Collaborated with upper management to drive strategy and implement new processes.
• Communicated and explained business requirements to team members to understand and implement functional demands.
• Offered input for complex documents to support client-ready final versions.
• Established strong relationships with key stakeholders, facilitating effective communication across departments and teams.
• Achieved significant savings by renegotiating vendor contracts, focusing on mutual benefits.
• Enhanced customer loyalty programs, analyzing customer feedback for continuous improvement.
• Developed and maintained strong relationships with key clients to ensure high levels of satisfaction.

• Provide accurate and timely loading of all professional provider contracts.
• Oversees the maintenance and termination of process through the appropriate research.
• Create contract templates to ensure accuracy for the entire team.
• Maintained high quality work while meeting or exceeding productivity goals.
• Communicate with Provider Relations when contract can not be administered properly.
• Perform high level Root Cause Analysis on SOX issues.
• Testing professional claims for critical errors as well as resolving those errors as to avoid future discrepancies.
• Act as an associate mentor and provide training to associates on departmental policies and procedures.
• Established best practices for configuration management, resulting in a more consistent approach across projects.
• Trained team members on configuration management tools and methodologies, fostering a culture of continuous learning and improvement within the organization.
• Collaborated with cross-functional teams to ensure proper implementation of configuration changes.

• Responsible for processing professional and institutional claims.
• Research and resolve complicated claims issues in a timely manner while consistently exceeding the quality standard.
• Handle Provider issue through web inquires, case logs and correspondence.
• Work closely with providers and provider representatives to resolve claim related issues. Work closely with internal partners such as Benefits and Configurations to ensure that claims are processed appropriately.
• Responsible for testing claims for various states and product lines including OH and NY MLTC.
• Participated in special projects, such as Hurricane Preparedness and the Sidewinder/ Softeon Migration.
• Provide support and side by side training to new hire associates.
• Recognized as Top Performer in the Claims Department by Management Team

• Responsible for handling incoming calls related to credit card issues, statements, customer complaints, building balances, general questions on accounts and de-escalating calls.
• As team leader, assisted manager with introducing new programs and policies to ensure appropriate education, training and motivation of associates.
• Organized team functions and contests for 20 associates to maintain positive morale and increase productivity.
• Reduced call time and idle phone time from 230 seconds to 190 seconds per call.
• Received team commendation for being “Best of the Best” team on site for 6 consecutive months.
• Recognized as Tampa Outstanding Performer (TOP) for achieving top 10% in overall performance for a 12 month period.