Jody Spells

Healthcare Operations and Claims professional with more than 20 years of healthcare experience, including 15 years working within the QNXT (Cognizant) platform, I have supported Medicare Advantage, Exchange, and Commercial PPO, HMO health plans through hands-on claims adjudication specializing in institutional claims. I have extensive knowledge in QNXT configurations of Claims, Plan, Sponsors and Benefits modules including copays, deductibles, accumulators and (CSR) functionality, along with Medicare pricing and Commercial contract terms. By taking ownership of my work, I have earned the trust of leadership to work remotely and independently while delivering dependable, high-quality results.

Following an organizational restructuring in September 2025, I began working independently in healthcare operations and AI support, using my experience to review automated workflows and AI-assisted outputs. I am currently open to independent contributor roles in healthcare business operations.

Independent Healthcare & AI Support Consultant at Self Employed (2025-09 – Present)

• Use generative AI tools, including ChatGPT and Microsoft Copilot, to support workflow testing, research, and documentation improvements.
• Apply healthcare operations experience in Medicare Advantage, Commercial pricing, and QNXT to review and improve operational data and workflow outputs.
• Review AI-assisted and automated outputs using healthcare claims knowledge.

Senior Compliance Consultant at Blue Cross and Blue Shield of Louisiana (2024-02 – 2025-09)

• Conducted compliance reviews to evaluate adherence to corporate policies, healthcare regulations, and applicable laws.
• Supported DOI, CMS, BCBSA, and Delegated Entity audits and examinations.
• Assisted leadership with regulatory responses, audit coordination, corrective action efforts, and compliance initiatives.
• Participated in special reviews and risk management activities.

Senior Business Analyst at Blue Cross and Blue Shield of Louisiana (2018-03 – 2024-02)

• Conceptualized using QNXT Cost Share Reduction capabilities to reduce benefit plans by 93% and reduced benefit plan creation time by 80% (highlight of my career).
• Served as Lead for back office BCBSLA/Vantage Medicare migration project, including ITS Home and Host implementation, and parallel testing.
• Implemented and tested Engage Cost Estimator Tool for (ACA) Affordable Care Act Price Transparency.
• Inter-plan (ITS) user acceptance release testing.
• Supported Medical Management and Claims Operations through reporting, testing, business analysis, and process improvement initiatives.
• Supported ClaimsXtens implementation and testing.
• Participated in workflow enhancements that increased productivity and reduced manual processing efforts.
• Supported MCAS, HEDIS, Risk Adjustment, ODAG audits, and regulatory reporting initiatives.
• Collaborated with Enrollment, Utilization Management, Finance, Provider Services, and Information Technology departments.

Claims System Analyst at Vantage Health Plan (2016-09 – 2018-03)

• Maintained benefit and plan configurations within QNXT for Medicare Advantage Exchange and Commercial health plans.
• Configured claims adjudication rules for professional, institutional, and ancillary services.
• Performed User Acceptance Testing (UAT), validation, and configuration analysis.
• Served as Liaison between Claims and IT, Benefits, Provider Services, Medical Management, Accounting, Enrollment, and Configuration teams.

Senior Lead Claims Examiner at Vantage Health Plan (2008-07 – 2016-09)

• Processed complex institutional claims for Medicare Advantage, Exchange and Commercial PPO, HMO health plans.
• Served as a senior resource for claims staff, assisting with claim processing questions, workflow coordination and operational support.
• Monitored claims inventory, productivity metrics and error tracking reductions through weekly statistical reporting.
• Collaborated with the Medical Director to identify DRG savings opportunities and support cost-containment initiatives.
• Participated in review and analysis of high-dollar, stoploss, outlier claims to ensure accurate reimbursement. Gained extensive knowledge in Medicare pricing methodologies and Commercial contract terms and pricing calculations. Worked with TPA's for contractual savings and negotiations. Assisted with Reinsurance processes.
• Assisted with provider contract, benefit, and claims configuration.
• Developed and maintained claims policies, procedures, and training materials.
• Created workflow improvements that increased productivity and reduced manual processing efforts.
• Served as backup support for leadership, including check run responsibilities and departmental operations.

Hospital Medicaid Billing, Managed Care Analyst, Physician Billing, Physician Receptionist at Progressive Healthcare Operations (1994-01 – 2008-07)

• Advanced through consecutive healthcare operations roles at Glenwood Regional Medical Center and Saint Francis Medical Center.
• Built 10+ years of expertise in hospital and physician billing of Medicare, Medicaid and Commercial claims.
• Loaded and maintained Medicare, Medicaid and Commercial contract terms using EYCMS contract management system.
• Detailed early-career role history is available upon request.

High School Diploma – Caldwell Parish High School