JOHN A. SANTOS Fox
RIO GRANDE
Summary
Skilled analytical professional with over 13 years of experience working with cross-functional teams and executing strategies. A highly motivated, holistic individual with a strong work ethic, a passion for data, well-being, adaptability, and exceptional interpersonal skills. Committed to supporting all business goals and objectives through positive change and a collaborative environment that encourages personal and professional growth.
Overview
21
21
years of professional experience
1
1
Certification
Work History
Medical/Financial Risk Evaluation Professional 2
Humana, Inc
San Juan
01.2019 - 01.2024
- Identify potential fraud schemes involving providers, prescribers, pharmacies, agents, members.
- Perform global data analytics research through PL/SQL.
- Gathered and organized data to analyze current industry trends.
- Identify opportunities for process improvements that will promote efficiency and accuracy.
- Collaborate with other departments, strengthening relationships to increase communication, and creating a focus on common goals to reduce FWA opportunities.
- Work on special projects, on request.
Medical/Financial Risk Evaluation Professional 2
Humana, Inc
San Juan
01.2017 - 01.2019
- Research and analyze (SQL/Excel) data for possible overpayments on incorrect billing processes.
- Lead/Collaborate team training sessions to help develop skills across the team in a collaborative setting.
- Identify opportunities for process improvements that will promote efficiency and accuracy.
- Collaborate with other departments, strengthening relationships to increase communication, creating focus on common goals to reduce missed overpayment opportunities.
- Work on special projects on request.
Provider Network Operations Analyst
Humana, Inc
San Juan
01.2015 - 01.2017
- Research and analyze (SQL/Excel) data for possible overpayments on incorrect billing processes.
- Create new queries/rules for the detection of overpaid claims.
- Create reports regarding pending queries to be worked on the process of financial recovery.
- Work on special projects on request.
Financial Aid Officer
National University College
Rio Grande
01.2012 - 01.2014
- Give counseling to students regarding federal student aid eligibility, funding, procedures, etc.
- Support students in the process of FAFSA renewal via the internet.
- Evaluate and award student aid funds in the CampusVue application, complying with federal guidelines, regulations and applicable laws.
- Give support to various Departments regarding student awards.
- Audit student awards in the CampusVue application.
- Complete institutional deadlines regarding student funding.
- Manage Federal Work Study Budget.
- Supervise In-campus students participating in the Federal Work Study program.
- Planned and implemented strategies to improve outreach efforts.
- Create Reports on request.
Quality Analyst
Medical Card System, Inc
Hato Rey
01.2005 - 01.2009
- Monitored completed work and provided feedback to improve team member performance.
- Identified quality trends to investigate system flaws, process inefficiencies and training needs.
- Conducted data analysis to prepare forecasts and identify trends.
- Utilized data analysis to monitor process efficiencies and identify data integrity exceptions.
- Generated standard or custom reports summarizing business, financial or economic data.
- Worked on Request for Proposals, Directories and Network comparisons among other Special Requests.
- Give support to other Departments regarding provider issues.
Claims Analyst
Medical Card System, Inc
Hato Rey
01.2003 - 01.2005
- Investigated and analyzed medical and pharmacy claims submitted by the IPAs for payment adjustments.
- Reviewed policies to determine appropriate levels of coverage and assist with approval or denial decisions.
- Perform Provider setting maintenance within the MHS system.
- Responsible for the preparation of various provider directories.
- Discussed current cases and pharmacy issues submitted by the IPAs in Pharmacy Department meetings.
Education
Bachelor’s Degree - Network Technology and Application Development
National University College
01.2018
Associate’s Degree - Accounting
National University College
01.2015
Associate’s Degree - Network Technology and Application Development
National University College
01.2013
Skills
- Bilingual
- Project management
- Cross-department collaboration
- Adaptability
- Critical thinking
- Analytical thinking
- Problem solving
- Process Improvements
- Identifying Opportunities
- Data analysis
- Statistics
- Microsoft Office
- Structured Query Language (SQL)
- Microsoft Power BI
- Leading a project
- Team Effectiveness
- Training people
- Well-being
- Building relationships
- Attention to detail
Certification
- Google Project Management
- Holistic Lifestyle Coaching (HLC) Level 1
- Healing fungal and parasitic infections
- Integrated Movement Science (IMS) Level 1
Languages
Spanish, English
First Language
Affiliations
- Martial Arts: Seibukan Jujutsu
- Volunteer - Para la Naturaleza
Accomplishments
CMS Provider Dashboard - Power BI Project
- Received the Bronze STAR Award in May 2022 for above-and-beyond contributions. Oversaw all phases of project management for our dashboard. A tool to help improve the efficiency, effectiveness and accuracy of our department's processes and/or daily work. It is a CMS provider demographic search engine with the capability to identify provider associations and affiliations, expanding our analysis capabilities while reducing search time. The major benefit of utilizing the tool is that it allows new and seasoned associates to focus on the investigative aspect of their work.
Timeline
Medical/Financial Risk Evaluation Professional 2
Humana, Inc
01.2019 - 01.2024
Medical/Financial Risk Evaluation Professional 2
Humana, Inc
01.2017 - 01.2019
Provider Network Operations Analyst
Humana, Inc
01.2015 - 01.2017
Financial Aid Officer
National University College
01.2012 - 01.2014
Quality Analyst
Medical Card System, Inc
01.2005 - 01.2009
Claims Analyst
Medical Card System, Inc
01.2003 - 01.2005
Bachelor’s Degree - Network Technology and Application Development
National University College
Associate’s Degree - Accounting
National University College
Associate’s Degree - Network Technology and Application Development
National University College
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