Lori Huber

Experience

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  Blue Cross and Blue Shield of Western New York

  Mar 1987 - Feb 2011

  Manager of Coordination of Benefits and Savings Recovery

  Began my career at BCBS of WNY in the Presciption Drug department as a clerk and quickly worked my way to a service representative that was responsible for writing processes and procedures for claim processing and system logic to ensure claims were calculated and processed correctly. I then moved up into a Medicare Secondary Payer representatie role that was responsible for maintaining member file information as it pertained to MSP reporting to CMS. My duties included processes of claims, correspondence, reconciliation of MSP dollars and servicing all aspects of this process with members, providers and CMS. This area was then absorbed by the Coordination of Benefits (COB) department. I then became very well versed in COB. I quickly took on additional tasks to assist management, in addition to driving system convesions, writing system logic for claim automation, training documentation and rolling out training to my co-workers in addition to management. I worked my way up the ladder to supervisor and then manager still within the COB area. My responsibilities increased to include Member Audits, Subscriber negative balances, Vendor relations, Claim Savings and Recoveries. Of course thru the years there were many system conversions that I was involved in - again identifying gaps and opportunities for automation and process growth. I continued to drive staff training in addition to the documentation and roll out. This area was a self contained unit driving all aspects of COB - claim processing, adjustments, servicing, correspondence, MSP, Auditing and recoveries. In addition, there was the reporting aspect of COB to ensure that dollars were being captured appropriately and being reporting to Senior Management to show the advantage of having a COB/Savings & Recovery area. This meant working very closely with Finance and IT to write the correct scripts associated with the system data. I also managed several relationships with recovery vendors. Show less

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  Connolly Healthcare

  Feb 2011 - Sept 2011

  HealthCare Auditor

  Very successful working as a HealthCare Auditor for the vendor Connolly Healthcare. I was responsible for identifying and recovering dollars associated with claim processing and claim procedures. I worked directly with a major Healthcare company in Western New York. Through the scrubbing of data and utilizing resources associated with their claim processing system and policies, I was able to identify Two Million dollars for this customer within a six month period. I was able to access their systems and familiarize myself with the interworkings and shortcomings of each system which led to inconsistencies in claim processing and gaps in claim logic which ultimately impacts the dollar which is being paid out to members and providers. These are the dollars that I targeted for savings opportunities. I was also able to identify some COB savings opportunities based on the manner in which they managed their COB processes. I also had the ability to write the logic of the queries and seek out additional opportunities within the Connolly auditing system. Show less

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  Independent Health

  Sept 2011 - Jun 2015

  Manager of Coordination of Benefits

  Manage a self sufficient department that is responsible for identifying and recovering Savings dollars associated with Coordination of Benefit (COB)dollars (including Coordination between Commercial, Medicare, Third Party, Workers Compensation and No Fault carriers) and dollars outside of the COB arena. My expertise is the ins and outs of COB and the manner in which it is applied. I also identify other avenues of opportunity within COB to show the cost avoidance that is obtained by managing the COB area efficiently. (Claim processing, adjustments, correspondence, servicing and vendors)In addition, i am highly experienced in the identification of savings dollars associated with claim waste, system issues, medical policies, procedures and mandates as they pertain to claim processing. This area is also responsible for verification and collection efforts on dollars that are not reconciled. These "negative balances" are collected, documented and reconciled in order to ensure monies are accounted for based on Retro termination (RX), Provider negative balances and Retro Terminated Premium dollars. Mandatory Section 111 processing and Medicare Secondary Payer (MSP) processes are also set up and driven through the COB area. To ensure that we are reporting correct COB data to CMS, I need to ensure the data being identified is accurate and supports the mandatory requests. We are also responsible for updating our records appropriately and communicating discrepancies to CMS to ensure the member is set up correctly and claims are processed appropriately. This also includes MSP PPN's and Demand letters for the Commercial side of business and Reconciliation of premium dollars associated with the Medicare Managed Care side.Within all these processes I am very successful in identifying gaps, non valued work and opportunities for automation . It is my responsibility to streamline processes and procedures to ensure a more efficient return on investment is obtained. Show less

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  Nova Healthcare Administrators, Inc.

  Jun 2015 - Apr 2017

  Cost Management Manager
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  Cotiviti

  Apr 2017 - Feb 2022

  Successfully lead a team of eight individuals for Innovation and Projects for a very large Health Insurance Company. Provide training to operations team in addition to IT requests, Data integrity, International Operations relationships, Projects and documentation of training materials and system templates. I have created a recorded presentation library that assists in the training of new and existing team members which assists with the in-person training lift. Responsible for reviews, mentoring and cross department relationships to ensure the success of our area. Work directly with Client Service Team to provide feedback and samples to share with client. Participate on Client calls and provide appeals and documentation to support our position. Show less Successfully continue to support the HealthCare Service Corporation (HCSC) team. This includes areas such as Provider Billing, Duplicates, Contract Compliance, Analytics/Support, Client Service Team (CST) and IO.• Identify and escalate Data issues to engineering and provide support and validation.• Generate and analyze reports for reporting and trending• Provide support and administration to IO team. Communicate changes, updates and training as needed• Create training documentation, workflows, recordings, training plans and provide training to team(s).• Enter and manage all tickets/JIRAs as they relate to data, access, reports and updates.• Established confident working relationships with IO, Analytics/Support, CST, Engineering, and other Senior Specialists on client teams. • Research and submission of concepts to the client for recovery opportunities. Identified other recovery opportunities that were categorized into an existing approved concept.• Point person on HCSC Automation projects. Identified automation opportunities, worked with Automation team, engineering and subject matter experts to complete these tasks. In addition to the creation of workflows and testing of tasks, I provided training and monitoring of the Bot kickoff and results.• Collaborate with Analytic and Support team on payment workflows and data mapping issues.• Established process and workflows for Provider outreach and Faxes to ensure requested information was provided and complete to and from the client• Partnered with other teams to identify additional opportunities and share knowledge on client data and systems to ensure a successful outcome. (Operation Growth Strategy, Duplicate team, Contract Compliance, Client Services, Analytics and Support, Anywhere Automation and Coordination of Benefits) Show less

  • Senior Specialist, Team Lead Payment Accuracy

    Oct 2021 - Feb 2022

  • Senior Specialist RCA

    Apr 2017 - Oct 2021
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  Point32Health

  Mar 2022 - Aug 2022

  Product Manager
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  Healthfirst

  Aug 2022 - now

  Senior Configuration Analyst