WORK EXPERIENCE

Confidential

• Approve claims payments up to 40,000 on personal authority. Processes medical claims of any type for multiple welfare plans according to established rules and guidelines.Claim ability include Hospice, ESRD,Coordination of Benefits,Outpatient, Inpatient, Skilled Nursing processing and billing,Rental DME ,Surgery Centers,Medicaid, Observation Room,Ambulance,Eligible issues, Adjustments,Interim Claims,Pricing Critical Access. . Research and process COB Coordination of Benefit claims. Capable of detecting fraud. Maintain working knowledge of medical terminology to interpret medical reports and bills to properly process claims. Update on current procedural terminology that changes annually. Determine proper payees. Utilize Facets System along with Ultera Imaging System to input and process claims. With advanced knowledge of Claimfacts systems.Perform any additional assigned duties as required by Management. Must meet quanity and quality standards.Qualify do research system PDQ for system managed data to update processing of claims for future use. Handle confidential information according to new laws HIPPA , experience with Emdeon/Relay Health clearinghouses.
• Meet production and quality goals for claim processing and payment.Perform claim adjustments and recoveries. Perform any other job related instructions as requested, with reasonable accommodation.Apply skills and experience to researching COB carrier information. Adjust related claims and resolve COB issues. Participate in training and act as a technical resource for new associates.. Review claims for possible fraud or abuse.Process hard copy claims when re-submitted with primary EOB. Business and analytical troubleshooting skillset. Act as lead, on various Facility claims that are having logic issues to ensure proper payments are being issued. Currently reviewing, updated and drafting P P's and job aides for Claims. Special projects and other duties as assigned. Adjust, correct and release claims facility and medical claims for priority providers. Research claims that may not be in the system for providers. Converse with providers on a daily basis regarding claims and their status. Pull documentation for providers that reference claims. Enter hardcopy claims for provider groups. Perform any other job related instructions as requested, with reasonable accommodation. Do testing of keying hardcopy claims for configuration . Including but not excluding Facility claims processing, adjustment, high dollar release authority up to 40k. Newborn claims and manual pricing.

Confidential

Sr. Claims Processor 3 Work At Home Associate

Insurance

• Processes medical claims of any type for multiple welfare plans according to established rules and guidelines.Claim ability include Hospice, ESRD,Coordination of Benefits,Outpatient, Inpatient, Skilled Nursing processing and billing,Rental DME ,Surgery Centers,Medicaid, Observation Room,Ambulance,Eligible issues, Adjustments,Interim Claims,Pricing Critical Access.Approve claims payments up to 35,000 on personal authority. Capable of detecting fraud. Maintain working knowledge of medical terminology to interpret medical reports and bills to properly process claims. Update on current procedural terminology that changes annually. Determine proper payees. Utilize Facets System along with Ultera Imaging System to input and process claims. With advanced knowledge of Claimfacts systems.Perform any additional assigned duties as required by Management. Must meet quanity and quality standards.Qualify do research system PDQ for system managed data to update processing of claims for future use. Handle confidential information according to new laws HIPPA . Ability to organize and analyze facts. Capable of acquiring medical information related to Medicare, cpt codes, ada codes and HIAA surgical table. Ability to understand medical and dental terminology and procedures. Must be able to use computer keyboard. Manage and process internal route boxes.
• Willingness and ability to assist Customer Service Representatives with questions and inquires. Document all second level support questions by utilizing and maintaining the Assist Line Tracking Database. Handle and resolve escalated member and provider complaints. Act as a role model to other Customer Service Representatives and employees. Display a positive attitude. Be helpful and approachable to other Customer Service Representatives and employees Ability to service both member and provider calls in all lines of business, existing and future. Utilize self-education opportunities to stay abreast of procedural updates maintain Subject Matter Expert SME status in all skill sets. Act as a mentor to new hire employees. Answer second level assist questions.

Confidential

Claims Processor

Processes medical, dental and Flexible Spending Accounts claims of any type for multiple welfare plans according to established rules and guidelines.Identify Workers' Comp claims. Coordinate with Medicare and other group insurance carries. Approve claims payments up to 15,000 on personal authority. Capable of detecting fraud. Maintain working knowledge of medical terminology to interpret medical reports and bills to properly process claims. Update on current procedural terminology that changes annually. Must be aware of legislative changes which affect welfare benefits plans and flexible spending accounts. Determine proper payees. Utilize Claims Facts System to input and process claims. Perform any additional assigned duties as required by Management. Must meet quanity and quality standards. Handle confidential information according to new laws HIPPA . Ability to organize and analyze facts. Capable of acquiring medical information related to Medicare, cpt codes, ada codes and HIAA surgical table. Ability to understand medical and dental terminology and procedures. Must be able to use computer keyboard. . Manage and process internal route boxes. Ability to service both member and provider calls in all lines of business, existing and future. Utilize self-education opportunities to stay abreast of procedural updates maintain Subject Matter Expert SME status in all skill sets. Act as a mentor to new hire employees. Answer second level assist questions. Willingness and ability to assist Customer Service Representatives with questions and inquires. Document all second level support questions by utilizing and maintaining the Assist Line Tracking Database. Handle and resolve escalated member and provider complaints. Act as a role model to other Customer Service Representatives and employees. Display a positive attitude. Be helpful and approachable to other Customer Service Representatives and employee

Confidential

Medical Benefit Administrator

Process claims for 15 companies through out the country with 40 different medical plans. Take incoming calls to verify eligiblity and give correct benefit information.I am also responsible for appeals and negotiations. . Manage and process internal route boxes. Ability to service both member and provider calls in all lines of business, existing and future. Utilize self-education opportunities to stay abreast of procedural updates maintain Subject Matter Expert SME status in all skill sets. Act as a mentor to new hire employees. Answer second level assist questions. Willingness and ability to assist Customer Service Representatives with questions and inquires. Document all second level support questions by utilizing and maintaining the Assist Line Tracking Database. Handle and resolve escalated member and provider complaints. Act as a role model to other Customer Service Representatives and employees. Display a positive attitude. Be helpful and approachable to other Customer Service Representatives and employees

SKILLS