This document provides a summary of Melissa Munoz-Espana's work experience and qualifications. She has over 15 years of experience in healthcare administration, revenue cycle management, and information systems. Her experience includes positions in healthcare organizations, health plans, and technology companies where she specialized in revenue cycle management, claims processing, provider relations, and data analytics. She is proficient in many healthcare IT systems and business intelligence tools.

1. MELISSA MUNOZ-ESPANA, MBA
10125 W. Sunrise Blvd. - Unit 301 phone: (954) 648 - 4201
Plantation, FL 33322 mmunoz1078@gmail.com
EDUCATION: Fordham University, Bronx, New York – BA - Biological Science (Pre-Medical), May 2004
Regis University, Denver, Colorado – MBA - Healthcare Administration, March 2011
Proficient in Microsoft Office, Quattro Pro, Word Perfect, QuickBooks, Outlook, Lotus Notes, Lotus Smart
Suite, Right Fax, Citrix, Facets, Mainframe, Epic, Sovera, IMAX, SIR, EZ Cap, Amysis, Emptoris, Portico,
Intergy, HEAT, SQL, Business Objects, and Practice Analytics.
6/2012 — 4/2014 Health Choice Network of Florida Doral, FL
Revenue Systems Analyst
• Monitor Intergy systems to ensure correct programming to support community health centers
• Monitor HEAT cases submitted by HCN staff or RCM Center Staff for Intergy system corrections to
facilitate claims submission, correct providers, and/or updates in Procedure Codes, Formats, General
Ledger, Profiles, or Fee Schedules
• Responsible for utilizing Practice Analytics to report on Accounts Receivable, claims payable, claims denied,
diagnoses (ICD-9 codes), procedure codes (CPT), and costs as related to the general ledger in Intergy
• Worked Extensively with business intelligence department to formulate reports that are unable to be drafted
with the sole use of practice analytics
• Lead on ERA initiative — automatic payment allocation via Intergy ERA portal
• ERA parameter setup for all managed care payers and each corresponding ANSI denial codes
• ERA parameter setup – set each denial code with appropriate action during ERA and payment posting
• Lead on ICD-10 project initiative to ensure Intergy and systems are prepared for new formats for ICD-10
• Manage Intergy for 15 centers to ensure correct reporting for UDS, General Ledger, and Accounts
Receivables
• Ensure setup is appropriate for all sliding fee schedules for each procedure performed for any given
patient (for self pay receivables)
• Ensure all 15 centers have correct Intergy setup to facilitate appropriate FQHC billing (by examining all EDI
claims, enrollment, and remittance files (837, 834, 270, 271, and 835)
• Ensure yearly poverty guidelines and associated sliding fee schedule changes are updated for all centers
• Utilize Florida Medicaid knowledge and contacts to facilitate RCM Billing
• Utilize Medicare knowledge base to facilitate RCM Billing
• Analyze managed care contracts to ensure appropriate setup for each insurance plan including Medicaid and
Medicare
• Analyze managed care contracts and load all appropriate fee schedules
• Perform analysis via different reporting mechanisms to identify various programming issues; such as
fee schedule loading, provider loading, profile loading, sliding fee schedule loading, and insurance
loading
• Ensure all claim formats are in compliance for 5010 and all Medicaid and Medicare formats
• Formulate system standards for Intergy loading of providers, claim formats, fee schedules, profiles,
procedures, and insurance plans
• Utilize and formulate reports to monitor RCM Center systems to ensure compliance and correct setup
2010 — 2012 Memorial Healthcare System Miramar, FL
Project Manager
• Utilized various PM methodologies to ensure compliance goals were being met regarding account resolution
and managed care payment
• Prepared legal cases against managed care plans for lack of appropriate payment per contract utilizing
hospital claims and patient systems such as Epic, Mainframe, and Sovera.
• Prepared reports to support legal cases utilizing Epic, Mainframe, and Business Objects
• Managed several contract compliance specialists and filing clerks
• Department expert on Florida Medicaid and Medicare (CMS) policies, procedures, and billing requirements
• Utilized Florida Medicaid and Medicare knowledge to obtain over 2.5 million dollars in old unpaid claims
that were initially denied for timely or billing issues
• Performed case by case research on in depth medical cases that are involved in non payment
• Analyzed medical records in order to appeal appropriate cases and build cases against managed care plans
• Analyzed managed care contracts to ensure appropriate payment for hospital and professional claims
• Performed trend analysis and identify claim payment issues for different managed care payers that
surround issues with billing, utilization management, and authorization insufficiencies
• Performed audits on work performance and accuracy for employees
• Prepared appeals and underpayments to managed care plans regarding loss of payment surrounding
medical or billing issues
• Performed coverage changes as it pertains to correct distribution of managed care funds
• Performed analysis and reporting to Executive Director regarding department goals, targets, account
volume with its corresponding monetary volume
EXPERIENCE:

2. 2006 - 2010 Pediatric Associates Health Plan Ft. Lauderdale, FL
Provider Relations Network Manager
• Functioned as liaison between the health plan and the participating provider network
• Performed accurate, detailed orientations for all provider types
• Understood and relayed current policies about benefit administration, enrollment, claims adjudication,
utilization management, quality management, credentialing, provider contracting and reimbursement to
health plan providers
• Functioned as a liaison between health plan and the state agency (AHCA) in regards to policy changes
• Managed and lead NPI implementation for health plan utilizing state and federal files and
contacts
• Oversaw and maintained delegated provider network relationships
• Ensured accuracy of provider data for in network and out of network providers
• Responsible for all delegation oversight responsibilities (auditing, contracting, provider updates, and claims)
• Produced yearly provider directory
• Produced monthly provider directory updates (provider directory addendum)
• Performed claims research utilizing Florida state file (ERV- Electronic Remittance Voucher, 837P and
8371 transactions)
• Educated providers on accurate claims processing utilizing CMS1500, UB-04 claim forms, and
HIPAA transactions (837P, 8371, 835, 834, and 270/271)
• Recruited providers into the health plan network
• Ensured potential provider applications are submitted through appropriate channels including
credentialing system loading of provider information
• Performed in-services for providers for the purpose of orienting new staff, communicating policy changes,
gathering or presenting statistical and financial data
• Coordinated and implemented all aspects of provider workshops, seminars and meetings
• Maintained accurate concise records of all provider contracts
2008 — 2009: Acting Director of Provider Relations
2009 — 2010: Transferred to Centene Corporation through sale of Pediatric Associates Health Plan
• Responsible for all of the above including utilizing business objects to report on Accounts Receivable,
claims payable, claims denied, diagnoses (ICD-9 codes), procedure codes (CPT), cost, and utilization
management analysis utilizing business objects for internal purposes as well as plan network providers
2004 - 2006 InnoMed Technologies, Inc. Coconut Creek, FL
Investor Relations Manager / Project Manager
• Responsible for investment reporting
• Managed national sales team and ensured appropriate staffing utilizing sales and sleep lab volumes
• Managed and organized sales reports, sales quantities and numbers, commission reports
• Organized monetary investments for all investors, including market shares and cash amounts
• Responsible for supply and demand analysis for appropriate ordering from manufacturers
• Performed trending analysis for patient utilization at sleep labs
• Designed and compiled Access databases to organize operations, product purchasing, and investment
logistics
• Organized investor portfolios and database
• Organized and formulated Access Database for all customers and 3,000 sleep study labs
• Prepared presentations for investors and clients
• Prepared all in services at all local sleep labs
2000 - 2001 IBM - T.J. Watson Research Center Hawthorne, NY
Department Manager / Executive Assistant
• Reported directly to Director and DGM of E-Commerce Department
• Supported senior managers of Intelligent Server Infrastructure, Advanced Cluster Technologies, Data
Management, and E-Commerce Departments
• Managed internship team of 10 - 20 interns
• Managed intern scheduling and project targets and formulate contingency plans as necessary
• Oversaw research department utilization
• Oversaw research department operations, including, but not limited to expenses, time allocation, and
project management
• Compiled utilization reporting, expense reporting, and savings analysis
• Organized all presentations and innovation meetings
References Available Upon Request