Sunitajain
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SUNITA JAIN
______________________________________________________________________________
216 Valley West Court, West Des Moines, Iowa 50265, sjain11@hotmail.com
PROFILE
Professional team player with exceptional analytical and problem-solving skills. Highly motivated with a passion for continuously improving aspects of the Health Care industry for both patients and providers. Proficiencies include research, writing and presenting on a variety of health-related topics.
PROFESSIONAL EXPERIENCE
Wellmark Blue Cross Blue Shield of Iowa May 1989 - Present
Medical Policy Research Analyst February 2008 - Present
• Researched, developed and implemented medical policies for new and emerging technologies
• Analyzed data provider utilization of services
Redeployment Program August 2007 – February 2008
• Networked with leaders from different areas, resulting in successful placement in a new role
• Utilized the Wellmark Learning Center's online catalog of courses to develop skills
• Assisted with the implementation of a project within Whole Health Dimensions, focused on writing and testing cases
Medical Review Clinical Analyst July 2003 – August 2007
• Performed medical reviews of provider records to discover “Failure to Discloseâ€� conditions
• Explained medical policy and benefit adjudication to internal and external customers
• Ensured proper payment of medical benefits according to company policies
• Provided ICD-9 and CPT coding consultation to various departments within Wellmark
Medical Policy Research Analyst January 1995 – July 2003
• Researched, developed and implemented medical policies for new and emerging technologies
• Created articles for provider newsletters to communicate changes in policies
• Analyzed data for Provider Profiling and provider utilization of services
• Provided codes to assist with HEDIS reports
• Researched and responded to providers' claims inquiries
Health Research Analyst October 1992 – January 1995
• Analyzed data for Provider Profiling and provider utilization of services
• Collected, maintained, analyzed and disseminated provider data to users
• Advised the Provider Credentialing Committee to assist in the selection of Blue Cross Blue Shield health products
• Searched and analyzed literature to establish clinical guidelines and lifestyle studies for employer reports
Systems Analyst, Medicare Part B October 1991 – October 1992
• Analyzed and implemented Healthcare Financing Administration (HCFA) mandates
• Updated Medicare fee schedules and established pricing
• Tested to determine inherent reasonableness for durable medical equipment
Profile Consultant, Medicare Part B May 1989 – October 1991
• Ensured that all technical details involved with the development and maintenance of providers' fee schedules for provider reimbursement were completed accurately and in compliance with HCFA guidelines
• Prepared training material for the Medicare staff
• Developed educational newsletters for the providers
Medical Review Coordinator, Des Moines General Hospital Clinics January 1988 – May 1989
• Reviewed all charge tickets for proper CPT and ICD-9-CM coding prior to billing
• Investigated denied claims for resubmission
• Educated the professional and clerical staff on billing and coding practices
Medical Records Technician, Iowa Lutheran Hospital January 1985 – January 1988
• Applied CPT and ICD-9-CM coding and on-line abstracting for hospital billing
• Reviewed medical records for appropriate DRG assignment
Medical Assistant, West Des Moines Internal Medicine Clinic April 1976 – January 1985
• Conducted laboratory, radiology, ultrasound treatments, phlebotomy, patient history and physical examinations
• Performed audits and appeals for denied claims
• Managed billing, book-keeping and accounting
EDUCATION
• Master of Science, Health Care Administration
Des Moines University, Des Moines, IA
• Utilization and Evaluation of Health Care Services Des Moines University, Des Moines, IA
• Comprehensive Medical Review Course
St. Barnabas Medical Center, New Jersey
• Bachelor of Medicine and Bachelor of Surgery (M.B.B.S.)
Rajendra Medical College, Ranchi, India
• Pre-Medical Certification
Hindu College, Delhi University, Delhi, India
ACCOMPLISHMENTS
• Served as an adjunct teacher at Hamilton College, Des Moines, IA
o Anatomy and Physiology
o Health Insurance and HCPCS & ICD-9 coding
• Served as Treasurer of AAPC (American Academy of Professional Coders) local chapter
• Received Certified Professional Coder (CPC) accreditation
• Achieved Managed Healthcare Professional (MHP) designation
• Achieved Health Insurance Associate (HIAA) designation
• Conducted coding workshop for allergists
• Consulted physicians privately concerning reimbursement and coding
• Conducted a two-day workshop for physicians and staff on Medicare, Medicaid, Blue Cross Blue Shield and HMO billing, coding and reimbursement guidelines
• Developed a comprehensive manual for physicians and clinic staff
• Served as a guest speaker at Des Moines University on ambulatory care and physician reimbursement
______________________________________________________________________________
216 Valley West Court, West Des Moines, Iowa 50265, sjain11@hotmail.com
PROFILE
Professional team player with exceptional analytical and problem-solving skills. Highly motivated with a passion for continuously improving aspects of the Health Care industry for both patients and providers. Proficiencies include research, writing and presenting on a variety of health-related topics.
PROFESSIONAL EXPERIENCE
Wellmark Blue Cross Blue Shield of Iowa May 1989 - Present
Medical Policy Research Analyst February 2008 - Present
• Researched, developed and implemented medical policies for new and emerging technologies
• Analyzed data provider utilization of services
Redeployment Program August 2007 – February 2008
• Networked with leaders from different areas, resulting in successful placement in a new role
• Utilized the Wellmark Learning Center's online catalog of courses to develop skills
• Assisted with the implementation of a project within Whole Health Dimensions, focused on writing and testing cases
Medical Review Clinical Analyst July 2003 – August 2007
• Performed medical reviews of provider records to discover “Failure to Discloseâ€� conditions
• Explained medical policy and benefit adjudication to internal and external customers
• Ensured proper payment of medical benefits according to company policies
• Provided ICD-9 and CPT coding consultation to various departments within Wellmark
Medical Policy Research Analyst January 1995 – July 2003
• Researched, developed and implemented medical policies for new and emerging technologies
• Created articles for provider newsletters to communicate changes in policies
• Analyzed data for Provider Profiling and provider utilization of services
• Provided codes to assist with HEDIS reports
• Researched and responded to providers' claims inquiries
Health Research Analyst October 1992 – January 1995
• Analyzed data for Provider Profiling and provider utilization of services
• Collected, maintained, analyzed and disseminated provider data to users
• Advised the Provider Credentialing Committee to assist in the selection of Blue Cross Blue Shield health products
• Searched and analyzed literature to establish clinical guidelines and lifestyle studies for employer reports
Systems Analyst, Medicare Part B October 1991 – October 1992
• Analyzed and implemented Healthcare Financing Administration (HCFA) mandates
• Updated Medicare fee schedules and established pricing
• Tested to determine inherent reasonableness for durable medical equipment
Profile Consultant, Medicare Part B May 1989 – October 1991
• Ensured that all technical details involved with the development and maintenance of providers' fee schedules for provider reimbursement were completed accurately and in compliance with HCFA guidelines
• Prepared training material for the Medicare staff
• Developed educational newsletters for the providers
Medical Review Coordinator, Des Moines General Hospital Clinics January 1988 – May 1989
• Reviewed all charge tickets for proper CPT and ICD-9-CM coding prior to billing
• Investigated denied claims for resubmission
• Educated the professional and clerical staff on billing and coding practices
Medical Records Technician, Iowa Lutheran Hospital January 1985 – January 1988
• Applied CPT and ICD-9-CM coding and on-line abstracting for hospital billing
• Reviewed medical records for appropriate DRG assignment
Medical Assistant, West Des Moines Internal Medicine Clinic April 1976 – January 1985
• Conducted laboratory, radiology, ultrasound treatments, phlebotomy, patient history and physical examinations
• Performed audits and appeals for denied claims
• Managed billing, book-keeping and accounting
EDUCATION
• Master of Science, Health Care Administration
Des Moines University, Des Moines, IA
• Utilization and Evaluation of Health Care Services Des Moines University, Des Moines, IA
• Comprehensive Medical Review Course
St. Barnabas Medical Center, New Jersey
• Bachelor of Medicine and Bachelor of Surgery (M.B.B.S.)
Rajendra Medical College, Ranchi, India
• Pre-Medical Certification
Hindu College, Delhi University, Delhi, India
ACCOMPLISHMENTS
• Served as an adjunct teacher at Hamilton College, Des Moines, IA
o Anatomy and Physiology
o Health Insurance and HCPCS & ICD-9 coding
• Served as Treasurer of AAPC (American Academy of Professional Coders) local chapter
• Received Certified Professional Coder (CPC) accreditation
• Achieved Managed Healthcare Professional (MHP) designation
• Achieved Health Insurance Associate (HIAA) designation
• Conducted coding workshop for allergists
• Consulted physicians privately concerning reimbursement and coding
• Conducted a two-day workshop for physicians and staff on Medicare, Medicaid, Blue Cross Blue Shield and HMO billing, coding and reimbursement guidelines
• Developed a comprehensive manual for physicians and clinic staff
• Served as a guest speaker at Des Moines University on ambulatory care and physician reimbursement