Veronica Middleton
Monmouth Junction,NJ
Summary
Accomplished Provider Data Service Analyst with a strong track record at QualCare/Enlyte, recognized for enhancing data accuracy and optimizing provider system updates. Proven expertise in data management and analysis, demonstrating proficiency in problem resolution while maintaining high-quality standards. Notable achievements include significant improvements in data processes and ensuring compliance with data privacy regulations within established project timelines. Career aspirations focus on leveraging analytical skills to drive continued process enhancements.
Overview
14
14
years of professional experience
1
1
Certification
Work History
Provider Data Service Analyst
QualCare/Enlyte
Monmouth Junction, NJ
06.2024 - Current
- Facilitated accurate system updates through detailed interpretation of Provider contracts.
- Oversee Provider Data maintenance for accurate claim provider selection, including both network and non-network providers.
- Maintains provider data accurately to facilitate member access and proper reimbursement.
- Manages baseline provider data transactions that require manual intervention due to system constraints.
- Worked on moderately complex issues by evaluating diverse factors to make informed decisions.
- Participated in the transition of QualCare through specialized projects.
- Assisted in retrieving Provider contracts and analyzing unfamiliar data from them.
Plan Implementation Senior Representative
QualCare/Enlyte
Piscataway, NJ
08.2021 - 06.2024
- Assigns the rate coding to ensure the system takes the appropriate discounts, per diems, case costs, and fee schedule
- Assesses fee schedules for compliance with coding standards.
- Selects, implements, and loads the system applications that administer managed care contract provisions
- Coordinates implementation and verification of the loading of the fee schedule
- Prepares the system entry to adjudicate contract provisions
- Creates and maintains networks and delivery systems in provider file system
- Identified areas for improvement, narrowing focus for decision-makers in making necessary changes.
Provider Operation Analyst
QualCare/Cigna
Piscataway, NJ
10.2020 - 07.2021
- Loading newly credentialed providers from Cred list into the Network
- Updating and adding offices on providers files
- Terming providers contract lines, offices, and network codes
- Adding/updating vendor names and addresses
- Special projects that have deadlines
- Terming provider from one tin and moving all of their data to another for a tin change
- Adding missing information or updating incorrect data on providers files
- Adding par providers to additional tins
- Doing provider changes/updates such as specialty and last name changes
Provider Setup Analyst
QualCare/Cigna
Piscataway, NJ
07.2012 - 10.2020
- Research and retrieve requested data
- Load provider contracts to pay claims
- Verify that providers have licenses to practice
- Communicate with providers to retrieve missing information
- Print and mail claims to providers in a timely manner to retrieve further information
- Create records for W9 retrieval
- Update provider vendor address per W9
- Respond to requests for information to be updated
Education
High School Diploma -
East Brunswick Vocational School
East Brunswick, N.J01.2001
Some College (No Degree) - Business Management
Middlesex County College
Edison, NJSkills
- Efficient Data Management
- Data Analysis
- Data Acquisition
- Thorough Review Practices
- Adaptable Learning Skills
- Experienced in Microsoft Word
- Microsoft Excel
- Microsoft PowerPoint
- Problem Resolution
- Data Privacy Compliance
- Maintaining Work Quality Standards
- Complaint resolution
- Adheres to Project Timelines
Affiliations
In my spare time I love to go to concerts, and I've recently started doing Lego.
Certification
I attended and completed a class on mastering Presentations through Powerpoint. Now I have the tools and abilities to present when necessary.
Accomplishments
I was of 20 workers to get nominated for employee of the year out of 1000 people
References
References available upon request.
Timeline
Provider Data Service Analyst
QualCare/Enlyte
06.2024 - Current
Plan Implementation Senior Representative
QualCare/Enlyte
08.2021 - 06.2024
Provider Operation Analyst
QualCare/Cigna
10.2020 - 07.2021
Provider Setup Analyst
QualCare/Cigna
07.2012 - 10.2020
High School Diploma -
East Brunswick Vocational School
Some College (No Degree) - Business Management
Middlesex County College
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