Yanet Cuevas

Experience

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  GHI

  Mar 1998 - Dec 2001

  Conduct audits on Membership: NYC and Commercial contracts, Time cycle. Prepare monthly reports, guidelines and bulletins.Review Medical Marketing Instruction Sheets and maintain log for historical files.Professional claims Audits and Special Projects Responsible for evaluating and approving HIP medical claims.Secured and confirmed information necessary to approve and adjust claims.Evaluated inquiries of subscribers and providers to validate and determine accuracy of payment.Report overpayments, underpayments and other irregularities.

  • Internal Audit Analyst

    Oct 2000 - Dec 2001

  • Medical Claims Approver

    Mar 1998 - Oct 2000
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  EmblemHealth

  Jan 2002 - Sept 2015

  Coordinate installation and testing of multiple systems: Mainframe, Network Access, Internet applications, EMC, GTESS and SeebeyondDesign test plans for systems modifications and additions. Conduct and control testing targets and parameters to ensure timely and accurate delivery of modifications and additions.Review Test Plans to ensure all requirements have been meet and test cases are accurate.Document traceability of test cases to business requirements via ALM system (Application Lifecycle Management). Document all defects, coordinate with IT staff members and vendor personnel as required within the document Test Plan.Identify, track, research and resolve system problems. Evaluate and recommend changes in modification/addition as well as methods and procedures for systems testing.Interface with IT Department and User Community to resolve systems issues.Lead on the implementation of ICD10 Project for all UAT Hospital system testing.Supervise, coordinate, and review the work of assigned staff.Serve as the SME for Hospital Claims systems on the implementation of new EPMO Projects. Coordinate installation and testing of OPTUM Products “Webstrat Software”, CMS Pricing, APC, APR DRG, New York State and ASC Pricing. Show less Supports all aspects of departmental programming implementation, from ITG development to testing of the finished product.Identify research and resolve Medical and Hospital Claim systems problems.Recommending and/or initiating systems corrections or modifications.Responds to internal telephone inquiries arising from rates and their development.Recommends systems enhancements required for contract implementation.Assist in training of corporate personnel on new system functions/changes, as needed.Provides research and special project support as directed by the Manager and/or Director.Perform other related duties as assigned.Responsible for the installation, uploading and testing of all Optum Applications. Show less Supervise a Staff of Medical Claim Approvers Responsible for the entry of Singles, Multiples, COB and Senior Care Claims.Responsible for monitoring the workflow of all claims processed.Prioritizing the distribution of work, provide training and directions to the employees.Preparing daily, weekly, and monthly production reports.Preparing weekly payroll and maintaining attendance records.Monitoring monthly production and work quality and initiating corrective actions as needed.Reviewing and approving ALGS letters.Perform Quality Audits in accordance with the Quality Program.dentifying trends in claim patterns and recommending changes in methods, system procedures and/or policies to improve the overall operation of the unit. Show less

  • Lead Business Analyst

    Mar 2011 - Sept 2015

  • Senior Business Analyst

    Nov 2003 - Mar 2011

  • Supervisor

    Jan 2002 - Nov 2003
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  CMO - The Care Management Company of Montefiore Medical Center

  Oct 2015 - Jan 2020

  Manager Quality Improvement
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  Healthfirst

  Jan 2020 - now

  • Senior Claims Manager

    May 2022 - now

  • Claims Manager

    Jan 2020 - May 2022