Vanessa Betancourt Monge
Orlando
Summary
Results-driven Healthcare Operations and Pharmacy Benefit Management (PBM) professional with 20 years of experience in Commercial, Medicare, and Medicaid health plans. Specializes in provider audits, claims adjudication, and pharmacy operations, focusing on discrepancy analysis, financial risk reduction, and regulatory compliance. Proven track record in process improvement and cross-functional collaboration within dynamic healthcare settings.
Overview
6
6
years of professional experience
2
2
years of post-secondary education
Work History
Senior Provider Audit
Centene
Remote-Orlando
2026.01 - Current
- Conduct pre-payment and post-payment provider claim audits to ensure compliance with CMS, Medicare, Medicaid, state, and organizational policies.
- Review provider documentation, medical records, contracts, and claims data to validate billing accuracy and compliance.
- Identified incorrect coding, billing errors, fraud, waste, abuse (FWA), overpayments, and processing discrepancies to ensure compliance.
- Manage complex audit caseloads and obtain supporting documentation for claim validation.
- Prepared detailed audit findings and recommended recoveries and corrective actions to address identified issues.
- Identify trends and root causes to support process improvement and payment integrity initiatives.
- Contributed innovative solutions to enhance team processes and outcomes.
Pharmacy Operations Coordinator I
Centene
Orlando
2024.01 - 2026.01
- Coordinated daily operations to enhance workflow efficiency across departments.
- Managed scheduling and logistics for team meetings and project updates.
- Developed training materials for new staff onboarding processes.
- Supported pharmacy benefit configuration, formulary updates, and client implementations.
- Performed quality assurance reviews to identify configuration defects and ensure system accuracy.
- Analyzed pharmacy claims and operational data to resolve benefit and adjudication issues.
- Developed SOPs, training materials, and operational documentation to support teams.
- Collaborated with cross-functional teams to improve workflows and ensure compliance.
Claim Quality Auditor
Centene
Remote-Orlando
2020.02 - 2024.01
- Investigated questionable claims to determine payment authorization.
- Completed required investigations on referred files within established timeframes.
- Conducted daily reviews on claim files and verified sending of status letters to policyholders.
- Evaluated evidence with the ultimate goal of creating positive outcomes for client's claims.
- Reviewed, evaluated and adjusted claims to promote fair and prompt settlement.
- Performed audits of claims systems to identify potential areas of improvement.
- Identified discrepancies in claims data and initiated corrective action.
- Served as a resource for other departments when questions arose about policy interpretation or regulatory compliance requirements.
Education
Bachelor of Science - Business Administration
Bachelor of Science, Business Administration – Ana G. Méndez
San Juan, PR 2024.06 - 2026.06
GED – Department of Education, Puerto Rico
San Juan, PRSkills
- Audit compliance
- Quality assurance
- Data analysis
- Process improvement
- Problem identification
- Problem resolution
- Team collaboration
- Employee training
- Training development
- Microsoft office
- MS office
- Computer skills
- Data entry
- Analytical thinking
- Multitasking
- Written communication
- Conflict resolution
Languages
English
Professional
Spanish
Professional
Accomplishments
- Led Average Wholesale Price (AWP) initiative generating ~$200,000 in revenue.
- Identified claims discrepancies resulting in nearly $100,000 in recoveries.
- Improved operational accuracy through proactive identification of system and claims issues.
- Supported multiple pharmacy implementations while maintaining compliance and quality standards.
Timeline
Senior Provider Audit
Centene
2026.01 - Current
Bachelor of Science - Business Administration
Bachelor of Science, Business Administration – Ana G. Méndez
2024.06 - 2026.06
Pharmacy Operations Coordinator I
Centene
2024.01 - 2026.01
Claim Quality Auditor
Centene
2020.02 - 2024.01
GED – Department of Education, Puerto Rico