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Skills

  • Workflow Optimization
  • Operational improvement
  • Budgets
  • Team building
  • Problem resolution
  • MS Office
  • Digital documentation and records management
  • Written and verbal communication
  • Cost reduction strategies
  • Data analysis and reporting

Work Experiences

  • Collaborated with third-party vendors to reclaim overpaid amounts, recovering an average of $6 per month.
  • Oversaw the delivery of method project by procedure team, which resulted in process.
  • Transported SAP to two years customer locations.
  • Achieved Employee of the Year for excellence in auditing accuracy and reducing the review time of high-risk claims by 2%.
  • Conducted regular team training.
  • Achieved zero audit penalties in 2015.
  • Achieved President's Club for excellence in auditing accuracy.
  • Contributed to reducing fraudulent payouts by $14 annually.
  • Collaborated with the fraud investigation unit, identifying suspicious claims which contributed to reducing fraudulent payouts by $10 annually.
  • Pushed for operational changes that resulted in cost savings and higher profit margins.

Summaries

  • Adept at delivering actionable insights.
  • Accomplished leader, recognized for driving departmental productivity through streamlined claims workflows and reducing audit review times by 67% for customer success.
  • Strengths in cross-functional collaboration and process improvement backed up by Miscellaneous training.
  • Acknowledged for refining policies.
  • Claims Audit Specialist with 12 years of successful performance reporting and risk assessment experience.
  • Empathy, dependability, and enthusiasm for customer satisfaction.
  • Accomplished Claims Audit Specialist with a strong background in fraud detection and revenue leakage prevention, supporting cost-saving initiatives by reducing fraudulent payouts by $2 annually.
  • Achieved $14 in reduced costs.
  • Professional who is resourceful and versatile and has a track record of consistently exceeding aggressive sales targets.
  • Achieved operational goals.

Accomplishments

  • Designed and led a corrective action plan to address compliance gaps, reducing reportable incidents by 54%.
  • Utilized data-driven analysis to identify claims trends, improving accuracy of future audits by 75%.
  • Conducted quality control reviews on 5 claims, ensuring audit standards were exceeded by 75%.
  • Implemented cross-department communication protocols, reducing miscommunications in audit processes by 59%.
  • Resolved product issue through consumer testing.
  • Proactively collaborated with external and third-party auditors, successfully passing compliance metrics with 59% accuracy.
  • Managed over 15 claims audits per month, maintaining a 32% accuracy and quality performance benchmark.
  • Helped reduce audit risk levels by reviewing 14 high-profile claims, identifying and resolving key areas of concern.
  • Collaborated with team of 9 in the development of process.
  • Partnered with cross-functional teams to identify audit discrepancies, resolving 41% of discrepancies pre-reporting.

Affiliations

  • Member of the National Council of Compensation Insurance (NCCI)
  • Certified in Health Plan Claim Auditing and Internal Control Programs
  • Active member of the American Academy of Professional Coders (AAPC) specializing in audit
  • American Institute of Healthcare Compliance (AIHC)
  • Professional Association of Healthcare Coding Specialists (PAHCS) Membership
  • American College of Healthcare Executives (ACHE)
  • Toastmasters
  • Healthcare Financial Management Association (HFMA)
  • Society of Human Resource Management
  • International Claim Association (ICA)

Certifications

  • Professional, Academy for Healthcare Management (PAHM) 2019
  • Professional in Health Care Management (PHM) – Vantage
  • Six Sigma Yellow Belt certification
  • International Organization for Standardization (ISO) 9001 Lead Auditor Certification
  • Certified Medical Reimbursement Specialist (CMRS)
  • Certified Professional Coder (CPC) - 2023, AAPC
  • Salesforce
  • Project Management Professional (PMP)
  • Certified HIPAA Professional (CHP) - 2021
  • Compliance Certification Board (CCB) Certified – 2021

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