Benefit Engine Architect Epic Coordinator Resume Example

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(555) 432-1000,
Montgomery Street, San Francisco, CA 94105
Professional Summary
Driven HealthCare Professional trained in all aspects of insurance billing, claims, configuration, appeals and collections. Employs high-level negotiation skills in resolving claims to the satisfaction of all involved parties. Analytical thinker and innovative problem solver.
Education and Training
, Expected in Certificate in Clerical Business Procedures, DeKalb Technical Institute : - GPA :
Skill Highlights
  • Healthcare billing proficiency
  • Problem resolution ability
  • Extensive medical terminology knowledge
  • In-depth claims knowledge
  • Critical thinking proficiency
  • Staff training and development
  • Personal and professional integrity
  • Claims Adjudication
  • Appeals Process

  • Certification/Proficiency Epic Benefit Engine Health plan
  • Certification/Proficiency Epic Benefit Engine AP claims
  • Knowledge of Epic Tapestry AP Claims.
  • Experience with Resolute PB and HB workflows.
  • EDI
  • IRCS proficiency
  • CMS Guidelines
  • Medicaid guidelines

Professional Experience
Exela Technologies Inc. - Benefit Engine Architect/Epic Coordinator
, , 06/2013 - Present
  • Develop benefits and benefit plans for all lines of business (HMO, DHMO, MC, and OOA) in the Epic system.
  • Responsible for accurate installations of group information, eligibility for all lines of business.
  • Resolves high priority CRMs when related to a benefit issue.
  • Process flow modifications for work queues.
  • Produce GCF reports daily and distribute amongst team for group completion status.
  • Work on projects.
  • Process groups received from sales/underwriting department.
  • Validate groups thru sales connect and track within the established SLA.
  • Handles weekly import to Bridges team.
  • Urgent email Issues from Managers.
  • Compare/Validate benefits between Common membership (CM) and Epic.
  • Update accumulator deductible/moop bucket when needed.
Kaiser Permanente - Refund Recovery Specialist
City, STATE, 09/2012 - 05/2013
  • Actively maintained up-to-date knowledge of applicable state and Federal laws and regulations.
  • Validate and review provider contract files received from external auditors.
  • Request refund and enter into the RTS tracking system.
  • Provider letters or phone calls to customer service.  Complete recovery sweeps to discover root cause of incorrect payment.
  • Process offset and duplicate refunds through manual check request for applicable regions and providers.
  • Researched and resolved billing and invoice problems.

Kaiser Permenente - Provider Appeals Specialist
City, STATE, 08/2010 - 09/2012
  • Process all Provider/HCI appeals for contracted and non-contracted providers (consideration for a denied claim).
  • Reviewed appeals for the following; denied for no authorization, level of care and PNC.
  • Ensured appeals contained proper documentation for review.  Reviewed appeals within the 60 day SLA turnaround time.
  • Upon decision, re-adjudicated claim for payment or processed denial letter to provider explaining reason for upholding the denial.  Resolved CRM’s routed from customer service dept. 
  • Interact with QRM for extensive/complex reviews.
  • Request medical records when all supporting documentation is not received.
  • Draft and submit extension letters to provider when 60 day SLA is not feasible.
Kaiser Permanente - Claims Adjudicator
City, STATE, 06/2006 - 08/2010
  • Process all lines of business (HMO, COMMERCIAL, MEDICARE AND MEDICAID claims) in a timely and accurate manner.
  • Handle special project for Coordination of Benefits, COB savings monthly.
  • Trained new hires and peers on COB.
  • Adjudicate employee confidential claims per compliance and state policies and procedures (PHI).  Resolve customer services inquires routed via CRM. Process adjustments.
  • Review and process foreign /fraudulent out of country claims.
  • Review and evaluate letters of complaints and appeals.
  • Works special project's relative to provider contracting, member benefits and quality review management departments to resolve system issues.
Blue Cross Blue Shield Of Georgia - Senior Claims Specalist
City, STATE, 07/1999 - 06/2006
  • Process complex and technical facility claims.
  • Handle sensitive accounts from Piedmont Hospital, St Joseph Hospital (Goodroe cardiac) Shepherd Spinal Center and Emory Hospital (heart transplants).
  • Analyze provider contracts.
  • Process large dollar hospital claims over $100,000.00 with efficiency and accuracy.
  • Process refunds/adjustments.
  • Cross train other associates.
  • Manage mail reports in absence of Supervisor.
  • Assisted Supervisor/Lead in resolving associate questions related to job functions and procedures.
  • Assist Utilization department with drafting instructional manual on process guidelines for Goodroe/DRG claims.
  • Facilitate team unit meetings quarterly.

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Resume Strength

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Resume Overview

School Attended
Job Titles Held:
  • Benefit Engine Architect/Epic Coordinator
  • Refund Recovery Specialist
  • Provider Appeals Specialist
  • Claims Adjudicator
  • Senior Claims Specalist
  • Certificate in Clerical Business Procedures, DeKalb Technical Institute

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