Career Summary

Diverse and progressively responsible experience within the insurance and retail industry with a focus on sales and customer service. Demonstrated talent in auditing, claim processing, and accounting functions. Particularly effective identifying and resolving client needs. Critical system skills:

Special Skills and systems

Windows 2000,Wordperfect, Lotus Notes, ICD10, Eighteen years of claims experience including Medicaid and Medicare DME and Part D, DRG, Dental, PPO,EPO, HMO, Rims, Ramba2,Blue chip, Mutual Of Omaha, Edi Viewer Front End, Crud Website, Test claims/Audit, Sales/Floor Director, Coding, Build Plan and Products, Revenue Recovery, Financial Analysis, Insurance Follow-up, Training/Supervision, Claim Administration, Credentialing

Professional Experience

Confidential

Business Analyst Tester Contract

Write test cases for ICD-10 scenarios and document on spread sheet. Test cases via spira test after uploading in the MMIS and Itrace systems. Review test cases with the policy department to insure tests are within the compliance guidelines.

Confidential

Claim Analyst I-Collections Contract

• Trained to process dental claims on the med advance and macess system. Claim examiners are responsible for reviewing dental claims for accuracy and compliance with group and DDPC processing guidelines and to process the minimum acceptable number of claims per day.
• Training to work as a collections representative with children's healthcare of Atlanta. Utilizing Epic, Xactimed, MMIS and Aspen training system.

Confidential

Claim Collections Contract

• Responsible for developing, implementing, view varies contracts for payment accuracy, maintaining and managing organizational policies regarding collection and HIPAA practices. Utilize CISCO WEB-EX, MS OFFICE WORD, EXCEL, and OUTLOOK , WEBMATS and SIEMENS HIS to appropriately document and perform the actions necessary to resolve assigned managed care accounts.
• Responsible for initiating the next billing, follow-up and/or collection steps, which may include contacting patients, insurers or employers, as appropriate. Also responsible for meeting and exceeding production/quality standards set forth

Confidential

Facets Analyst Open Enrollment Contract

• Run validation queries in Microsoft Access to analyze Standard and Cobra Medical, Incentive Rewards, Pharmacy, and Medical Management Plans and Products in order to cross reference/map/and configure into Siebel Customer Resource Management Client System.
• Run Queries in Inteligroup and then configures Pharmacy Plasm/Farkey values and Rate Quotes for Community and Experienced rated Groups in Sail to Mail and Siebel CRM systems.
• Configure the following in Facets 4.71 and 4.61 for all new and active groups benefit changes : Class/Plan Definition, Premium Rate Table, Groups, Subgroups, Billing Entity and Subscriber Family applications.
• Handle specialized activity such as Marketing Priorities and Action Requests.
• Validate and configure enrollment codes for various PPO, Commercial and HDHP Health Plans such as High Deductibles and Copays.
• Audit co workers configured contracts for management.

Confidential

Senior Claims Specialist Contract

• At Dell Perot Systems:
• Processed medical claims using Trizetto Facets 4.71 and Networx pricing applications as well as crosswalks, and grids to ensure provider contract compliance for Universal American, Houston, Texas.
• Resolved professional CMS 1500 as well as facility UB-04 claim edits on the Xcelys system, Utilized the Softheon, Edi Viewer, Citrix, and Knowledge Base System for Community Health Plan of Washington.
• Priced professional CMS 1500 as well as facility UB-04 claims on the GP00 Facets System, Utilized Networx to complete Rate Sheet, Provider ID, Network/PID for Non-Par Providers. Utilized the Ingenix Rate Manager. Completed other processes, including WGS, Ultera, and sending 06 Messages on the NAPS/ITS system for WellPoint Ohio.
• Reviewed claims on the MHS and ITS system at BCBSNC to determine status. Sent letters to providers to process claims.
• Finalized medical professional CMS 1500 as well as facility UB-04 claims on the Qcare and Macess system for Kaiser Permanente Denver.
• Analized medical health claims on the, LSRP, NASCO, Diamond, Macess, and ITS systems, Utilized the Ingenix Rate Manager. Sent 06 messages and letters to the Home Plan via NAPS/ITS for payment for Blue Cross of Rhode Island, and Blue Cross of Jacksonville Florida
• At Jacobson Solutions:
• Reviewed claims on the MHS and ITS system at BCBSNC to determine status. Sent letters to providers to process claims.
• Reviewed provider DEA, College Board, and Provider Board websites to obtain information to credential provider files for board review. Great West Life Denver Colorado.
• Utilized Macess and Facets to process Customer Service calls for Medicare Part D open enrollment, which included adding primary providers, reviewing family and individual maximums, deductibles, co pays, and process premium payments for Rocky Mountain Health Plan Grand Junction, Colorado.

Confidential

Accountant-Dental Department FTE

• Served as primary resource person for dental department on unclaimed property, customer service adjustment requests, and overpayments.
• Adjusted accounts for the accounting department.
• Issued appropriate correspondence to clients and providers to expedite the claim process on overpayments, or refunds and responded immediately to prompt quick resolution.

Confidential

Auditor- Customer Service Contract

• Assisted in member services by providing information regarding enrollment and benefits to members and providers.
• Reconciled accounts due to partial or full refunds to ensure accurate accounting.
• Promoted within first month from claims reviewer to auditor due to accurate analysis of medical data and plaintiff information for national lawsuit.
• Calculated additional payments and reissued to proper claimant. Seabury and Smith Dallas, TX

Confidential

Staff Claim Unit Associate FTE

• Rectified daily accounts through executing payments/analyzing deductible payments to the policyholder. Subrogated overpayment accounts with other carriers.
• Received several awards from management in recognition for accounting accuracy. This resulted in company receiving national service award twice for revenue recovery.
• Issued appropriate correspondence to clients and providers to expedite the claim process on overpayments, or refunds and responded immediately to prompt quick resolution.