SUMMARY:

• Motivated, personable, healthcare professional with a successful history of medical claims experience. Talent for quickly mastering technology. Diplomatic and tactful at all times; professional in manner and appearance. A good listener with exceptional interpersonal skills. Excellent communication, presentation, organizational and planning skills. Accustomed to handling sensitive and confidential information.
• Involved in implementation of FACETS systems (built and tested)
• Strong knowledge of Medicare, Medicaid, and commercial claims processing guidelines
• Have adjudicated, audited, trained, performed UAT and benefits testing and recovered monies for the following claim types: Medicare, Medicare Supplement, Medicaid, Vision, Inpatient/Outpatient Mental Health and Substance Abuse, Physical Therapy, Chiropractic, Dental, Skilled Nursing Facility (Long - term Care), Indemnity, Durable Medical Equipment, Surgery, Anesthesia and Prescription Benefit Management
• Extensive knowledge of ICD-9 coding, CPT coding, HCPCS coding and medical terminology

TECHNICAL SKILLS:

PROFESSIONAL EXPERIENCE:

Confidential, Philadelphia, PA

Quality Assurance Specialist

• Knowledgeable and proficient in the Argus adjudication platforms used for clients, AmeriHealth
• Administrators and Independence Blue Cross.
• Contract position.
• Analyzed plan design set up for accuracy through understanding client documentation and other source documentation to interpret client intent and ensure appropriate coding and claim adjudication.
• Utilized both manual and automated testing processes to determine the accuracy of benefit coding.
• Reviewed benefit testing and data output to ensure that claim results meet the documented client expectation.
• Utilized defect tracking software to report and track findings as required
• Reported defects identified during testing to appropriate departments, consistently, until resolved.

Confidential, Philadelphia, PA

Research Analyst

• Contract position.
• Functioned as a technical specialist for claims enhancements operations.  Via FACETS analyzed complex operational claim payment problems and provided technical solutions.  Identified and recommended areas where changes to existing processes and procedures could result in process and/or cost savings.
• Provided support to claims examiners, customer service, and provider claims service reps.
• Responded to and resolved provider and health plan claim inquiries.  Input claims into the system for appropriate tracking and processing.  Provided documentation, as appropriate, to support payment decision.
• Maintained a current working knowledge of processing rules, contractual guidelines, plan policies and operational procedures to effectively provide technical expertise.
• Resolved and provided direction on complex cases, utilizing strong investigative and research skills.
• Identified process gaps and trends providing explanations and feedback to staff and management.
• Identified key issues with projects and offered solutions.
• Maintained a balance of productivity, quality, and timeliness of job accountabilities.  Completed pre and post disbursement reports.  Identified and defined problems and opportunities within the work area and attempted to resolve through appropriate channels.

Confidential, Chicago, IL

Claims Analyst

• Remote, contract position.
• Via FACETS claims processing system, was responsible for the timely resolution of ITS BlueCard-Home, “system error” claims that were the result of claims processing errors and/or system configuration issues.
• Regularly exceeded quality and production standards as set forth.

Confidential, Fort Washington, PA

Quality Assurance Analyst

• Audited high dollar claims to ensure accuracy in adjudication, pricing, etc.
• Audited the entry of benefit installations of new and existing groups.
• Was accountable for identifying ITS BlueCard and third party claim adjudication errors, which were attributable to claims analyst’s errors, system application errors, data entry errors or group benefit installation errors.
• Conducted live audits, performance guarantee audits and random audits. Reported accuracy of claims in the areas of payment, technical and payee error.
• Was responsible for entering relevant data and maintaining Microsoft Excel spreadsheet on the quality statistics of each analyst while complying with mandated turnaround times.
• Analyzed audit errors to locate and report weekly error trends.
• Maintained current awareness of operational, procedural and contractual guidelines, while maintaining an excellent performance rating in both production and quality statistics.
• Performed SAS 70 reviews on group benefit installations and updates.
• Audited Provider File Support updates and changes as related to SAS 70 guidelines.

Confidential, Bala Cynwyd, PA

Claims Processor II

• Contract position.
• Analyzed the daily fall-out of E.D.I. claims to ensure accuracy and prompt payment.
• Ran daily report via Excel and analyzed data to avoid duplicate claim payment of E.D.I. claims.

Confidential, Chicago, IL

Healthcare Consultant

• Recovery Auditor ~ Audited ITS BlueCard claims adjustments related to vendor refunds, to ensure examiner’s accuracy in adjusting and properly applying vendor refunds to erroneously paid claims.
• Quality Review Auditor ~ Audited samples of processed claims for various plans products and services.
• Recovery Specialist ~ Adjusted professional and institutional claims via FACETS Claims Processing system to recoup monies paid in error due to COB and Subrogation overpayments.
• Claims Adjuster ~ Adjudicated claims in response to client’s backlog and to Customer Service inquiries via FACETS (Trizetto) claims processing system.
• Provider Services Representative ~ Worked with Operations in enhancing Call Center volume while meeting corporate goals and providing outstanding customer service on the telephonic system and FACETS Customer Service Inquiry System.

Confidential, Philadelphia, PA

Recovery Specialist

• Member of leadership team that successfully built upon existing B.I. Query Data Warehouse application in order to meet specific business needs.
• Performed UAT testing as a member of leadership team that successfully built, tested and implemented Coordination of Benefits Extension to FACETS claims processing system.
• Interfaced and communicated with Director/Manager/Supervisor to ascertain appropriate steps for best possible recovery results regarding system and training issues.
• Under the direct supervision of the Supervisor, Manager, and Director of the Recovery Unit, was responsible for the handling of claim adjustments for all Lines of Business for the Cost Containment Unit.
• Investigated claims thoroughly with the intent to adjudicate, using all available resources including original claim submittals, attachments, explanation of benefits and/or follow-up letters and responded in the required time to internal/external clients, attorneys, providers, members, insurance companies and state agencies.
• Thoroughly documented findings within the required timeframes and took steps to resolve issues, clearly stating the facts so that other plan representatives could communicate directly with internal/external clients, attorneys, providers, members, insurance companies and state agencies about the same matter.
• Responded to all telephone inquiries regarding COB and Cost Containment within the required timeframe.
• Utilized system applications including FACETS, Microsoft Excel and Access, B. I. Query and Data Warehouse for obtaining and manipulating data for file reporting, summarizing information as needed for COB and Cost Containment reporting / issues.
• Adhered to reporting requirements, accurately provided, tracked and monitored data used for reporting purposes and production within the required timeframe.
• Responded to and/or updated EXP and/or e-mails within the required timeframe.
• Consistently exceeded Cost Containment standard, maintaining financial and procedural accuracy in the handling of claims.

Claims Examiner II

• Processed various claim types, including, surgical, inpatient, outpatient, ER, dialysis, etc.
• Re-processed claims via projects under the direction of Claims department management.
• Assisted new employees in processing guidelines.
• Assisted in monitoring new employees’ progress through auditing.