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Meet Our Principal Claims Expert
(Resume Synopsis)
Betsy M. Rychlewski
R.N., B.S.N., MBA
Education
Keller Graduate School of Management
Downers Grove, Illinois
Masters of Business Administration - 1992
Northern Illinois University
B.S.N. - 1979
Career Summary
I have over 24 years of extensive experience in the managed care and insurance industry and exhibit thorough
understanding of healthcare policies, benefits and reimbursement methodologies. I am skilled in
negotiating contracts and communicating with clients and demonstrating leadership ability while collaborating
with teams to achieve organizational goals. I am passionate about helping individuals with planning,
protecting and managing their health and wealth.
Experience Highlights
Medical Matrix Systems, LLC
Health Care Consultant:
- Claims reviews
- Medical necessity
- Creative billing
- Expert systems development
- Centers of Excellence
- Case management
- Appeals
- Many other managed care initiatives
Medical Claims Review:
- Furnish advice and assistance in a clinical capacity regarding plan provisions and medical claims - annualized savings of $9 million
- Provide clinical support to customer service, claims, special investigation unit, legal, compliance, sales and marketing regarding benefit interpretations, customer inquiries, and access to providers.
- Provide oversight monitoring of all facets of Utilization Review and Case Management of the contracted Utilization Review Agents
- Established a working team comprised of claims, compliance, customer service, training, and managed care to review State Regulations and Legislation in order to review for applicability to the products and implement processes to ensure compliance.
- Participate and contribute in new clinical program development, such as: disease management and neonatal case management.
Developed managed care strategies, Centers of Excellence - Specialty Networks
- Cardiovascular
- Transplants
- Home Health
- Ancillary Services
- Cancer Centers
- Catastrophic Case Management
- Neonatal Case Management
Responsible for the areas of PPO Network development and management
- Renegotiate existing contracts
- Improve eligibility process to the networks
- Improve network compliance by providing monthly updates of provider listings
Director of Medical Services
Responsible for the areas of:
- Medical Claim Review
- Utilization Management
- Quality Improvement
- Credentialing
- Full range of financial analysis for contracting with physicians, hospitals and other vendors
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