Athena Afford
Burnsville
Summary
Senior Risk Adjustment Analyst skilled in enhancing risk scores and ensuring encounter data compliance with CMS regulations. Demonstrated success in preparing for regulatory audits and leading cross-functional projects that improve claims processes and operational efficiency.
Overview
19
19
years of professional experience
Work History
Sr. Risk Adjustment
Medica Health Plan
Minnetonka
01.2021 - Current
- Identified opportunities to enhance risk scores and quality metrics through in-depth data analysis, contributing to improved compliance and accuracy.
- Ensured compliance of encounter data submissions to CMS/DHS with regulatory requirements, identifying and resolving data issues.
- Evaluated medical data to identify trends and ensure accurate HCC payment.
- Supported regulatory audit readiness, including RADV, by validating medical records and ensuring accuracy of reported diagnoses, facilitating successful audits.
- Supported government audits through precise data analysis and comprehensive documentation.
- Led cross-functional projects, managing vendor partnerships and providing analytical support for internal initiatives.
- Collaborated with external vendors to streamline encounter submissions for CMS/DHS, improving submission accuracy and efficiency.
- Examined EDI data (835/837) to troubleshoot submission errors and enhance data integrity.
- Assessed requirements for project development.
Data Billing Specialist
Rs Eden
Minneapolis
04.2018 - Current
- Manage MN DHS Service Agreements, ensuring correct authorization and billing alignment and adherence to state requirements.
- Verified client SALs and authorizations through MN-ITS system to ensure billing accuracy.
- Generated invoices and tracked payments using billing software, ensuring accurate client records.
- Updated client information within HMIS system to maintain data integrity and compliance.
Configuration Analyst I
Medica Health Plan
Hopkins
05.2018 - 12.2020
- Entered and managed provider agreements and contract data with a focus on timeliness and accuracy.
- Updated provider information, enhancing claims accuracy and ensuring data reliability.
- Facilitated contract deployment and client onboarding, promoting smooth operational integration.
- Tracked and processed service requests through ServiceNow, driving system enhancements and improving workflow efficiency.
Claims Operations Analyst
Medica Health Plan
Hopkins
12.2015 - 05.2018
- Investigated overpayment issues to establish solutions for claim recovery.
- Resolved claims issues through thorough investigation of checks and refunds, enhancing accuracy.
- Managed complex claims with specialized attention, achieving timely resolutions.
- Collaborated with cross-functional teams to optimize claim operation processes, enhancing overall workflow.
- Executed special projects, generating reports and conducting internal audits that supported operational improvements.
Claims Processor III
Medica Health Plan
Hopkins
08.2013 - 11.2015
- Processed and resolved complex medical claims, including workers’ compensation and auto insurance, ensuring timely and accurate payment.
- Evaluated policy and procedure documents, ensuring adherence to guidelines and compliance.
- Investigated checks and payments to identify and resolve discrepancies efficiently.
DME Billing Coordinator
Park Nicollet Health Care
Minneapolis
05.2011 - 08.2013
- Prepared and processed Medicaid DME claims and invoices, ensuring timely reimbursement.
- Addressed and corrected claim denials by identifying billing errors and resubmitting claims to maximize approval rates.
- Monitored and managed aging accounts and zero pay remits to reduce outstanding balances.
Medical Biller
Hennepin Faculty Associates
Minneapolis
09.2007 - 09.2010
- Coordinated with third-party payers to obtain status updates, resolve denials, and secure timely payment.
- Identified and corrected billing errors for Medica, BCBS, and HP, ensuring accurate claim processing.
- Reviewed billing information in EPIC system to ensure accuracy and maintain up-to-date patient account records.
- Resolve payment issues for work comp and auto claims ensuring accurate and timely reimbursement.
Education
Bachelor of Science - Finance
Metro State University
St Paul, MN12-2024
Associates of Applied Science - Accounting
Minneapolis Community and Technical College
Minneapolis, MN05-2011
Skills
- Claims management
- Revenue cycle management
- Claims processing
- Investigating claims
- Healthcare billing systems
- HMIS expertise
- Financial analysis
- Data analysis
- SQL analysis
- Configuration Management
- Microsoft Office
- Training and development
- Client relations
- Policy development
Timeline
Sr. Risk Adjustment
Medica Health Plan
01.2021 - Current
Configuration Analyst I
Medica Health Plan
05.2018 - 12.2020
Data Billing Specialist
Rs Eden
04.2018 - Current
Claims Operations Analyst
Medica Health Plan
12.2015 - 05.2018
Claims Processor III
Medica Health Plan
08.2013 - 11.2015
DME Billing Coordinator
Park Nicollet Health Care
05.2011 - 08.2013
Medical Biller
Hennepin Faculty Associates
09.2007 - 09.2010
Bachelor of Science - Finance
Metro State University
Associates of Applied Science - Accounting
Minneapolis Community and Technical College