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Click here or scroll down to respond to this candidateCandidate's Name
Phone: PHONE NUMBER AVAILABLEE--mail: EMAIL AVAILABLEPROFESSIONAL PROFILETalented, energetic, and dedicated claims examiner with 20 years of experience handling medical and commercial claims. Extremely detail-oriented professional focusing on accuracy and thoroughness of work delivered. I possess strong communication and interpersonal skills for interacting with supervisors, team members, and customers. Highly motivated self-starter with a strong work ethic to increase productivity in the workplace.Computer skills: Power MHS Processing, RIMS MHC, TAPESTRY, Macess, Facet, Microsoft Office Amisy Provider Test claims, QNET 5.6 Epic Tapestry Next Gen (Excel, PowerPoint, Outlook, Word) EPP Epic Payer PlatformCore Competencies: Claims Management, Claims Processing, Claims Handling and Investigations, Policy Interpretation, Confidential Records Management, Reporting and Provider reimbursement, Claims configuration, Documentation, Creative Problem Solver, Analytical Decision Making, Team Building & Collaboration, Budget Preparation, Data Entry Provider Extracting Date from the EpicPROFESSIONAL EXPERIENCEHBCS June -2022- PresentMedical Biller SpecialistAccurately applied payments patient accounts issued from insurance companies and/or private account monitored benefits and claim statues for all claims on file. Oversaw Accounts Receivables Management for both vendor and insurance company payments. Generate biweekly expense reports with detailed summaries of explanation. Confirmed and approved all charges entered daily, monitoring physician ICD-9 and CPT coding according to CMS guideline. Acted as the insurance liaison in maintaining and updating of all insurance contract for the company.REMOTE CLAIMS EXAMINER November 2021- June 2022PRICE WATERHOUSE ADVISORYAdjudication and benefit plan application for indemnity plans, HMO plans, POS plans, Medicare and Medicaid.Processing adjustment for overpayment and underpayment on claims denials.Track and report on any overpayments recovery utilizing refund process.Ensure proper benefits are applied to each claim by using the CMC/Medicare guidelines.Insure manually pricing is accurate and appropriate.CLAIMS SPECIALIST April 2018 April 2020JOHNS HOPKINS HEALTHCARE LLC, Baltimore, MarylandManage, investigate, evaluate, and negotiate moderate to high exposure complex coverages for medical claims configuration of test in Amisy system.Interact daily with customers taking statements and research medical records to understand the nature and extent of injury and medical conditions.Evaluate medical claims for potential fraud issues, loss control, and recovery in accordance with insurance policy contracts, medical bill coding rules, and state regulations.Document claims files accurately and promptly while maintaining company metric goals.Provide excellent customer service while delivering information in high stressed situations.Assist internal and external customers with problems or questions regarding claims while providing a high level of customer service.Partake in an exclusive testing of Priority Partners benefits for the merging of the Health suite processing system.Worked Provider reimbursement, Provider Test end user testing UAT application in the Amisy system.Correspond with various departments in order to execute claims within a 30-day time frame.CLAIMS PROCESSOR April 2016 February 2018DOMINION NATIONAL, Arlington, VirginiaProcess claims in accordance with the claims processing system and other department guidelines.Investigate reverse and reprocess claims in a timely fashion.Review provider and/or member status to determine eligibility, participation, primacy, and correct reimbursement level, which may include re-pricing.Determined if claim submission was completed correctly, verified data and entered into system for adjudication.Provided independent decision-making skills and demonstrated initiatives to resolve issues for internal and external customersPerformed clerical functions which included opening, sorting and distributing incoming mail and processing outgoing mail, copy work, filing and assisted the unit and supervisor in multiple projects using expert time management.Investigated and resolved customer inquiries and concerns in a timely and empathetic manner.CLAIMS ADJUSTER/AUDITOR October 2014 April 2016JACOBSON INC., Chicago, IllinoisProcess and adjust professional liability and institutional health claims In the Macess and QNXT system.Review communications from providers and others who requested an audit of the initial liability payment recommendation.Respond to by conducting my independent audit/review to determine if the payment was made in accordance with the policy terms and conditions.Identified problems, troubleshoot, and provided guidance to claim analyst.Conducted daily review of pending claims and prepared weekly audits for each claim.Contributed to the development of claims analysis reports.Reviewed claims to ensure that claims are appropriately processed.SR. CLAIMS EXAMINER/CUSTOMER SERVICE October 2011 October 2014HEALTHSMART BENEFITS SOLUTION, Irving, Texas,Processed for payment complex medical claims for various insurance carriers.Maintained and organized claims documentation including financial, account and medical information.Resolved medical claims by conducting document examinations and reviewsAdjudicate both inpatient and outpatient medical bills in accordance with policy and legal terms.Coordination of benefits with other responsible parties, which included subrogation.Manage a high volume of calls from doctors, medical facilities, claimants and defense counsel.Follow proper client and state regulations to ensure compliance with appropriate guidelines.Macess and QNXT system.EDUCATIONBachelors, Major in Business Administration, Prairie A&M University, Prairie View, Texas (continuing)PROFESSIONAL LICENSE |
