Claims Recovery Specialist
Hard-Working Team Player Who Goes Above and Beyond to Resolve Issues for Providers
Insurance claims processor with experience in medical billing and claims for healthcare insurance and provider accounts. Customer-focused with demonstrated success working with providers and accounts payable to research and resolve billing issues. Communicate effectively with wide range of healthcare provider departments.
Enjoy interacting with and assisting people, explaining complex billing issues in ways that are clear, accurate, and understandable. Team player who gets along with co-workers and has a positive attitude. Detail focused, with excellent time management skills. Experienced in training and customer service.
Microsoft Office Word, Excel, Outlook
Kaiser National Applications:
Macess EXP, Diamond, Kmate, Hyperspace
Kaiser Web Applications:
IBM Lotus Notes
Cardozo Sr, High-Diploma-1987-1991
CAHPS - Received outstanding survey score
MAS Claims Processing Training
MAS MACESS Tracking Workflow Training
Received recognition award for collecting $1,000,000 a month for a difficult account.
Claims Recovery Specialist01/2009 to CurrentKAISER PERMANENTESilver Spring, MD
Charged with recovery of claims overpayments in high-volume operation.
Perform claims quality assurance audits to measure accuracy and completeness of reported claims overpayments submitted to Recovery Department from QCT&R auditors, CRU, and Account Management Team.
Communicate with providers and participate in recovery negotiations.
Respond to inquiries and communicate status of issues.
Coordinate and report payments in Excel documents.
Reviewed billing paperwork, ensuring accuracy in claims processing.
Worked independently with assigned groups of providers, recovering claims overpayments identified by various audit groups.
Performed separate jurisdictional screening and quality review of overpayments received from various audit groups, identifying claims that were not recoverable due to state / federal rules and regulations or other reasons.
Prepared reports of findings.
Facilitated quality improvement within department by working closely with Recovery Supervisor.
Entered scrubbed claims overpayment spreadsheets into Claims Administration Recovery System database (CARS), ensuring accurate reporting and documentation.
Presented findings in interdepartmental meetings to representatives from Provider Relations, Contracting, and Legal departments.
Participated in negotiations and communicated with providers, ensuring timely follow-up on recovery letters.
Worked with providers to further explain identified overpayments and reconcile KP position with provider's position, obtaining acceptance of overpayments.
Maintained tracking tool of recovery progress, preparing weekly and monthly reports for management.
Eliminated claims overpayments by performing root cause analysis and proposing appropriate corrective actions.
Performed special projects, reconciliations, research and analysis, contributing to quality claims processing improvements.
Provided accurate, compliant, and timely support to Claims Administration business activities, ensuring activities were in compliance with different organizational, regulatory, and industry standards.
Claims Processor / Examiner, Claims Administration01/2001 to 01/2009
Adjudicated members' claims in accordance with contract, status, and Health Plan department principles.
Primary responsibility for payment or denial of all claims and the appropriateness of changes.
Handled member inquiries about status of specific claims, responding in accurate and understandable manner.
Provided timely processing and adjudication of claims.
Researched and resolved benefit and membership status questions from member services relevant to adjudication, bringing trends and significant policy issues to management's attention.
Cultivated and maintained working relationships with referral center, membership representatives, and membership accounting, ensuring timely, accurate processing.
Articulated basis for decisions on claims payment to members based on knowledge of policy, procedure, and precedent.
Radiology Film LibrarianKENSINGTON MEDICAL CENTERKensington, MD
Fulfilled requests for radiology films.
Scheduled appointments with focus on customer service.
CashierSAM'S CLUBLaurel, MD
High School Diploma1991Cardozo Sr, HighWashington, DC
Account Management, accounting, billing, Business Objects, customer service, database, documentation, Email, focus, IBM, Legal, letters, Lotus Notes, meetings, Excel, Microsoft Office, Outlook, Word, negotiations, organizational, progress, quality, quality assurance, quality improvement, radiology, reporting, research, spreadsheets, Supervisor, Web Applications, Workflow