THUY THAI
Jacksonville
Summary
Self-motivated Team Member with the ability to work effectively in a fast-paced environment Exhibits effective decision-making, organizational and problem-solving skills An unwavering commitment to provide exceptional customer service with the ability to build productive relationships, resolve complex issues and win customer loyalty Strategic-relationship, team-building skills, active listening skills, critical problem-solving ability, intermediate use tact and diplomacy to find common ground and achieve win-win outcomes Advanced Proficiency with the following applications: TriZetto Facets, QNXT, Legacy AS400, Amisys, Health Rules, Optum, ALM Quality Suite, CES, Claims Xten, JIRA, SharePoint, Application Lifecycle Management, JIRA, Microsoft Office Applications, Oracle SQL, Microsoft Access
Overview
12
12
years of professional experience
1
1
Certification
Work History
Senior Configuration Analyst
Molina Healthcare
02.2023 - Current
- Analyzed and interpreted complex provider contracts, ensuring accurate configuration in QNXT.
- Built provider contracts in QNXT including contract terms, pricing methodology, Credentialing, PCP Assignments, and Auth Processing.
- Configured new provider contracts, amendments, and State Regulator fee schedule updates.
- Created Fee Schedules and Qualifier Groups in to streamline configuration process.
- Updated Provider Demographics and Contract Information.
- Configured Service Groups and Restriction Groups; updated Contract Terms.
- Built and Maintained Providers for Claims Payment, Credentialing, PCP Assignments, and Auth Processing.
- Generated and analyzed Provider Related reports to facilitate and support Provider Services and Provider Problem Research and Resolution.
- Conducted paper contract analysis, state and provider fee schedule analysis, load file analysis and prepared load files for importing.
- Resolved Claims Errors and Configuration updates through analysis and configuration design to promote Claim Auto Adjudication.
- Set up various payment methodologies, including capitation, fee-for-service, and value-based payments.
- Configured claims processing rules to ensure accurate adjudication based on provider contracts.
- Tested and validated configurations for accuracy and compliance with contract terms.
- Maintained provider data integrity through regular audits and updates.
- Troubleshooted configuration issues and resolved problems related to provider contracts and claims processing.
- Provided support to internal and external stakeholders on QNXT configuration and contract-related issues.
- Stayed up-to-date on industry regulations and participated in system upgrades and implementations.
- Collaborated with claims processing, provider relations, and other departments to ensure smooth operations.
Configuration Analyst
Clark Staffing (EMIDS)
07.2016 - 01.2023
- Configured provider contracts, including demographics, specialties, contract terms, reimbursement rates, and fee schedules; Configured benefit plans, including eligibility rules, covered services, cost-sharing provisions, and limitations. Set up various payment methodologies, including capitation, fee-for-service, and value-based payments.
- Analyzed and interpreted provider contracts and benefit plan documents, ensuring accurate configuration in QNXT.
- Tested and validated configurations for accuracy and compliance with contracts, benefit plans, and regulations.
- Conducted gap analysis and root cause analysis as needed.
- Reviewed and documented current provider contracts and QNXT configuration.
- Created an implementation plan for building and implementing provider contracts in QNXT.
- Maintained provider and benefit data integrity through regular audits and updates. Troubleshooted configuration issues and resolved problems related to provider contracts, benefit plans, and claims processing.
- Provided support to internal and external stakeholders on QNXT configuration, provider contracts, and benefit-related issues.
- Researched and corrected claim reject codes.
- Resolved claims errors and configuration updates through analysis and configuration design to promote claim auto-adjudication; created desk-level procedures for manual claim adjudication.
- Developed and maintained documentation for provider contracts, benefit plans, and QNXT configurations. Collaborated with claims processing, provider relations, member services, and other departments to ensure smooth operations.
- Reviewed benefit grids to extract business requirements needed for medical plan configuration.
- Created design documents and executed configuration in response to related compliance/regulatory/accreditation reports.
- Ran SQL queries to conduct data analysis.
Business Owner
TEE NAILS
03.2017 - 06.2022
- Results-driven entrepreneur and business owner with [14 years] of experience building and scaling successful businesses. Proven expertise in operations management, sales growth, strategic partnerships, and team leadership. Known for turning challenges into opportunities, driving profitability, and delivering outstanding customer satisfaction.
- Business Development & Growth Strategy
Sales & Marketing Leadership
Operations & Process Optimization
Financial Management & Budgeting
Customer Relationship Management (CRM)
Hiring, Training & Team Leadership
Contract Negotiation & Vendor Relations
Problem-Solving & Innovation
Quality Testing Lead
Clark Staffing, Aetna
09.2014 - 06.2016
- Create and execute various types of test cases (end-to-end, regression, smoke, ad-hoc, unit, UAT) using manual and automated tools. Develop test claim scenarios, steps, and outlines based on business requirements.
- Review business requirements, identify deficiencies and gaps, and link test cases to both business and technical requirements.
- Ensure test data is linked to test cases, compose data for test automation, and review data extracts to create reports.
- Report, track (in JIRA), resolve, and retest defects; update test cases based on discovered issues.
- Serve as a liaison between technical and non-technical departments. Facilitate daily stand-up meetings and participate in test team meetings, client demos, and walkthroughs.
- Create daily/weekly progress and risk assessment reports. Develop training documents, process documentation, and tester aides. Provide training to testers and cross-functional staff.
- Provide work estimates, meet daily/deadline goals, document risks and issues, and escalate barriers to the Delivery Manager.
Senior Claims Specialist
Clark Staffing, Anthem
09.2013 - 08.2014
- Reviewed and adjudicated complex, sensitive, and specialized claims according to processing guidelines. Applied medical necessity guidelines, determined coverage, completed eligibility verification, and identified discrepancies. Adjudicated, pended, and denied claim payments based on coverage and guidelines.
- Researched and ensured accurate claim information, including edits, procedure codes, diagnosis codes, coordination of benefits, and utilization requirements. Resolved provider inquiries and claim discrepancies.
- Composed and disseminated appellant determination letters, notifying members and providers of final determinations. Performed claim rework calculations.
- Reviewed and adjudicated claims pended to various workflow queues. Developed and executed desk-level procedures for claims failing auto-adjudication.
- Improved provider relations by resolving claims inquiries and discrepancies. Supported call center activity by providing information on member eligibility, claim status, and provider inquiries.
- Distributed work assignments to junior staff. Trained and mentored new hires and peers.
- Met performance goals in efficiency, accuracy, quality, member satisfaction, and attendance. Remained compliant with CMS transmittals, CPT, HCPCS, ICD-9, and ICD-10 code sets.
Education
High School Diploma -
A Phillip Randolph High School
Jacksonville, Florida06.2007
Skills
- Configuration: Provider data, fee schedules, payment methodologies (capitation, fee-for-service, value-based), claims processing rules, benefit plan configuration, eligibility rules, plan-specific edits; Benefit plan configuration, eligibility rules, covered services, cost-sharing, limitations, claims processing rules, pre-authorization requirements, plan-specific edits
- Contract Analysis: Review, interpretation, legal terminology, reimbursement models, quality metrics
- Benefit Plan Analysis: Plan design, eligibility criteria, covered services, cost-sharing, limitations
- Healthcare Industry Knowledge: Reimbursement methodologies, coding systems (CPT, HCPCS, ICD-10), benefit plan types and lines of business
Certification
- Certified Scrum Master
- Scrum Alliance December 2024
Languages
Vietnamese
Native or Bilingual
Timeline
Senior Configuration Analyst
Molina Healthcare
02.2023 - Current
Business Owner
TEE NAILS
03.2017 - 06.2022
Configuration Analyst
Clark Staffing (EMIDS)
07.2016 - 01.2023
Quality Testing Lead
Clark Staffing, Aetna
09.2014 - 06.2016
Senior Claims Specialist
Clark Staffing, Anthem
09.2013 - 08.2014
High School Diploma -
A Phillip Randolph High School
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