Senior Configuration Analyst
NTT Data Global Delivery Services
Total des années d'expérience :8 years, 10 Mois
• Successfully implementing benefit plans within Health Rules Manager (HRM), enhancing system eficiency and accuracy
• Spearheading the implementation of provider contracts in Health Rules Designer, ensuring accurate claims adjudication
• Leading end-to-end configuration projects using HRM Designer & Manager, improving process eficiency
• Developing basic scripts and dynamic logic utilizing Groovy, a Java-syntax-compatible programming language, to automate and streamline operations
• Gaining expertise in Oracle Health Insurance (OHI) application, optimising health insurance
processes
• Conducting thorough claim testing to verify system accuracy and reliability
• Utilising SQL to manage and manipulate data, enhancing database management and reporting capabilities
• Designing and implementing solutions to automate processes, significantly improving customer service eficiency
• Playing a key role in the Magellan Healthcare Reporting & Analytics Project, driving insights and
operational improvements
• Collaborating with the Automation Development Team to identify and implement process enhancements
• Managed and resolved insurance disputes and appeals based on denial/medical necessity reviews and compliance, improving patient access and financial outcomes
• Initiated appeals for cases referred by AR follow-up and the onshore client using E-Pars and PAS Portal, based on comprehensive analysis of previous follow-ups and remittance data
• Specialized in denial management, effectively reducing the volume of denied claims and facilitating quicker reimbursements
• Coordinated the request and reconciliation of medical records to support the appeals process and ensure documentation accuracy
• Functioned as an AR Caller, identifying root causes of insurance denials, appealing to payors, and
collaborating with consumers and insurance representatives to resolve outstanding balances
• Focused on Revenue Cycle Management, specifically targeting underpaid claims to secure correct reimbursement amounts
• Expertise in denial management and insurance verification, ensuring accurate billing and
minimizing financial losses
• Managed rejection posting and write-of balances according to provider agreements, maintaining financial integrity and compliance