A skilled and qualified professional with more than ten years of experience in the health care and insurance industry. Strong problem-solver with excellent time management skills. Detail-oriented with proven skills in medical terminology, reimbursement, medical policy and contract language and organizational skills. Focus on developing high standards of quality while meeting established metrics and deadlines, evaluating current processes for effectiveness and implementing necessary changes to programs and policies. Specialist in Medicaid statutes and management information systems while providing superior customer service that aids in client retention. Advanced skills in claims processing, case rate assignment and repricing, and end-user testing. Software skills including Microsoft Word, Excel, PowerPoint, Outlook, Amisys, CRM, AWD, DCS, Mbi, ECI, MMIS, Macess, Business Object, Emdeon, EDI and other systems utilized to maintain fee schedules and HIPAA regulations. Significant exposure to provider contracting for Medicaid/Medicare and commercial contracts. Knowledge of ICD-9 and CPT codes. Strong communication and negotiation skills.
Demonstrate analytical and problem-solving ability by addressing barriers to receiving and validating accurate Provider information. Actively maintain up-to-date knowledge of applicable state and Federal laws and regulations.Provide thorough execution for day-to-day operations of department objectives in accordance with set policies and guidelines. Audit spreadsheets containing Provider Rosters and demographics. Liaison between contracting and credentialing to ensure providers are correctly loaded and oriented. Serve as a primary resource web portal registration and troubleshooting. Claims review to determine accuracy of claim decisions and monitor claim activity to determine trends. Outreach, prepare and coordinate reports for management and State agencies. Created formulas to automate reports tracking Provider Availability. **Previously served as Member/Provider Services II from March 2010-June 2012.
Responsible for initial eligibility determination for disability claimants. Educate claimants and employers on FMLA and disability guidelines. Receive and enter medical information for physician's statements, while making determinations. Review medical records for appropriate treatment and compare to establish guidelines and job descriptions. Sound decision-making based on respective state guidelines within multiple jurisdictions and clients. Served as mentor and trainer for new and current Analysts, and also providing audits before graduation release. Developed cheat sheet for new hires to serve multiple LOBs. Point of contact for escalations and provided authority to execute processor judgment.
**Promoted to Senior Analyst.
Adjudicate health insurance and dental claims within production goals and guidelines. Reprice claims based on negotiated fees. Use of medical terminology for correct coding and clinical guidelines. Verified patient eligibility and correct provider networks. Created a decision matrix for case rate processing. Requested medical records based on coding.Review contracts and assign pay classes and applicable provider information based on contract language. Testing systems to ensure correct fee schedules are utilized and aligned with contracts. Appropriate referrals to UM for extended medical review. Proficiency in COB calculations, subrogation monitor, identification and review. Acted as primary contact for programmers loading new contracts into claims payment system. Investigate any questions or issues during the initial implementation process, while recommending solutions and requesting enhancements.
**Lead Examiner for largest account.
Processed flexible spending account reimbursement requests according to IRS guidelines. Manage and audit flex debit card transactions. Reconcile and manage 21 accounts for various employer groups. Compare contract language with IRS guidelines.Primary contact for IRS legislation and updates; responsible for communicating any changes. Managed employer's census for employer groups to ensure employees were terminated or added timely. Provided customer service for all accounts. Produce weekly flex reimbursement payments to claimants.
**Promoted to Team Leader
**Received Healthcare Specialist Certification
Reviewed and audited medical and dental information, request records when necessary. Received incoming calls for all accounts, Processed health insurance claims including outpatient, inpatient, therapy, DME, and behavioral health claims. Audit new hires and subject matter expert (SME) on multiple accounts. Liaison to recovery unit to assist with identifying overpayments.
Companies Worked For:
Job Titles Held:
© 2019, Bold Limited. All rights reserved.