Laguna Niguel, California, United States
As a Data Integrations Analyst, claim’s researcher, auditor, project manager and team lead, I have accumulated experience and skills that are very valuable in data analytics. These experiences include running SQL Queries, Crystal Reports, heavy use of Excel and Visual Studio Code to analyze and refine data, quality control auditing, performing root cause analysis, identifying criteria to extract desired data from databases, detail communications of findings to all appropriate parties and developed and refine processes to maximize efficiency.
Data Integrations Analyst II Analyzed medical claims data to create mapping logic for ETL processes, ensuring seamless data integration. Used PostgreSQL to validate, format, and normalize data, collaborating closely with project managers, operations teams, and clients to establish clear data milestones. Data was used to create medical action items for business clients. Key Accomplishments: • Developed ETL blueprints for implementation in AWS, ran the ETL workflows, and performed thorough QA in Snowflake and Looker to verify accuracy before deployment. • Managed data pipelines —pulling files from SFTP, uploading them to S3 in AWS, and running orchestration processes. • Using DataGrip, validated data counts against raw sources to ensure integrity, worked with engineering to resolve any ETL issues, and committed high-quality data to the database through detailed analysis and queries. • Promoted from Data Integrations Analyst I after 6 months employed.
Dedicated full-time to raising two young boys to school age, fostering their physical, emotional, and educational development. Key Accomplishments: • Managed household operations, schedules, and responsibilities with efficiency and adaptability. • Developed strong problem-solving and multitasking skills while handling diverse daily challenges. • Organized and implemented early childhood education activities to nurture curiosity and learning. • Maintained a structured, positive environment conducive to personal growth and family well-being. • Coordinated logistics for school readiness, extracurricular activities, and health-related appointments.
Performed light management duties for a team of 19 Project Owners including: Training, quality control, attend policy meetings, and document management in addition to continuing responsibilities of a Project Owner. Key Accomplishments: • Created and administered team documents in a SharePoint site. • Identified SQL report criteria required for data research to assist with management decisions and process improvements. • Analyzed weekly reports consisting of details related to all open projects within my team to ensure timeliness and accuracy. Worked with the project owner to ensure proper handling and escalation of their projects. • Led team members by providing guidance and direction on complex projects. Acted as a help desk for questions related to the job. Provided new member training. • Worked with various departments to develop new or changing processes. Updated PnP docs, created step-by-step documents in Word and rolled out the changes by conducting the necessary training. • Performed team audits and attended audit meetings. Trained and supported the new audit team. • Hosted weekly meetings with examiners to discuss issues related to open projects. • Provided administrative support to management by accomplishing any delegated tasks in a timely manner. • Continued to perform all duties of a Project Owner
Provider-Initiated Projects Used front end database tools to research large volumes of disputed claims submitted by providers to determine the validity of the dispute by checking claim specific data against the contract. • Performed root cause analysis in order to identify primary reason for errors and worked with appropriate entity to resolve the issue. • Identified and resolved the breakdown in the retro process resulting in missed claims. • Managed the adjustment process of incorrectly paid claims through report generation and heavy Excel spreadsheet work. • Identified data elements that could be used to research claims efficiently through Excel. Used those elements to generate a report through Access. • Audited claims utilizing Excel formulas and tools, provided comments detailing the research results for each claim and scrubbed spreadsheet to ensure compatibility with our database then imported the clean data into the database. • Managed the system routing tools to ensure each claim was triaged to the appropriate department for adjustment. • Ensured timeliness of the project to meet regulation guidelines utilizing the escalation process when necessary. • Exported final results from SQL using Access into an Excel file and audited for accuracy and prepared for presentation. • Submitted written communication of outcomes to all parties involved and continued educational discussions as necessary. Retroactive Projects • Researched retroactive system updates to determine whether claims adjustment may have been negatively impacted. • Identified data elements, such as: Date of service, CPT codes, procedure codes, diagnosis codes, etc., to generate a report that includes only the impacted claims. • This often results in reports with tens of thousands of rows of raw claim data to be analyzed and scrubbed utilizing Excel formulas and tools. • Managed the same adjustment process as above including generating a final outcome report and communicating to applicable parties.
Researched disputes from providers utilizing tools such as contract data held in IBM S400 databases, SQL databases and an imaging database to determine whether a processing error may have occurred. Worked with the appropriate department to pay/adjust the claim or communicate to the provider the decision to uphold.