Gladys Perez Hilty

Facets Configuration Consultant with extensive experience in benefits, claims, and utilization management configuration across Medicare and commercial lines of business. Proven ability to analyze complex rules, support pre-authorization workflows, and ensure configuration accuracy aligned with clinical and regulatory requirements. Strong background in stakeholder collaboration, configuration auditing, and SQL-based data validation and analysis.

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Senior Facets Configuration Consultant Contractor with Cumberland Consulting Group/Project: BCBS of KC  Project team member assessing, configuring and auditing configuration.  Analyze configuration across Medicare Advantage business.  Audit claims against current configuration to insure the current Medicare Advantage benefits are applying correctly.

 Project team member assessing, configuring and auditing configuration.  Analyzed configuration across commercial lines of business.  Validated current configuration against the Policy Summary of Benefits.  Worked with the Facets Configuration Team to build over 500 new products for the 2021 project for Shell 1 and Shell 2 builds.  Configuration of Product Tables (Service ID’S, Benefit Summaries, Service Payment, Service Rule, Billing Components, etc.)

 End to end configuration for medical, dental and vision plan in the testing system and live Luminex claims paying system.  Improve build configuration and automation to efficiently manage the release of CPT/HCPCS codes.  Developed and implemented 16 insurance plans into the Luminex claims payment system reducing the time taken to build a plan from 8 hours per client per plan to 1 hour per client per plan.  Strategic plan implementation with organizational goals, policies, quality assurance, and growth objectives.  Collaborate with sales reps to guarantee the accuracy of all information for new and renewal business.  Tasked with providing HIPAA and federal ACA compliance.  Critical in preparing new and renewal submissions and proposals.

 Maintained 4.8 out of 5 ratings on performance values in benefits configuration, audits, and time management for Medicare-related products.  Configuration of Product Tables (Service ID’S, Benefit Summaries, Service Payment, Service Rule, Billing Components, SPCT, SRCT, SEDF)  Wielded deep expertise in leading research into installation and benefits issues to develop resolutions specific to individual customers.  Worked with BPA tables for supplemental mapping when appropriate.  Conducted audits into contract benefits and pricing configuration.  Validated current configuration against the Policy Summary of Benefits.  Benefit configuration for Medicare and Medicaid members in Facets Applications.

 Improved productivity; by reducing the amount of re-dos by 70%.  Partnered with the actuarial team to test and utilize the Rate Setup Sheet used along with the rating engine.  Effectively communicated with the Billing Director to certify the correct accounting and CODA coding was set up for the new coverage codes.  Trained new employees on the completion of rate sheets as the Plan Documents that were sent to clients lining out the company’s benefits.

 Generated more than $10,000 in savings for clients by creating the plan documents in-house as opposed to the use of external vendors  Served as the go-to subject matter expert for benefit contract interpretation and execution for self-funded plans.  Liaised between clients and the company to independently resolve all service problems.  Prepared medical benefit contracts (SBC and SPD) in compliance with ACA requirements.

 Achieved and maintained a no-pay percentage of 2.85% through the provision of excellent customer service, outperforming the corporate target of 13%.  Forged productive relationships to create a pool of prospective clients from various sources.  Evaluated business and individual customers’ needs and financial status and proposed protection plans that met their criteria.