Experience

Total Health Care

• United States
• Insurance
• 100 - 200 Employee

• Account Manager

  • Apr 2018 - Present

  Completes monthly renewals for 250 groups and all maintenance of them. Provides group information to agents and employer groups regarding renewals and other group information when requested. Attends benefit enrollment meetings when necessary and/or requested by the group or agent. Completes monthly renewals for 250 groups and all maintenance of them. Provides group information to agents and employer groups regarding renewals and other group information when requested. Attends benefit enrollment meetings when necessary and/or requested by the group or agent.



Meridian

• United States
• Hospitals and Health Care
• 700 & Above Employee

• CLAIMS RECOVERY SPECIALIST

  • Apr 2016 - Apr 2018

  Works directly with Management in resolution of high level complaints relating to COB/Liability issues.Over sees Medicaid compliance rules and timely reporting of information for COB related state complaints.Completes all COB/Liability/MVA appeals.Trains all new employees within the COB Department and development of all policies and procedures within the COB Department. Over sees, tracks, and completes all COB requests that require additional assistance through Meridian's request in box.Investigation/verification of new and exciting members with TPL information. Identify possible repcoupement opportunities and/or reprocessing of claims.Assisted with COB testing for system updates with IT Department. Show less

• CLAIMS EXAMINER III

  • Apr 2009 - Apr 2016



Molina Healthcare

• United States
• Hospitals and Health Care
• 700 & Above Employee

• CLAIMS AUDITOR II

  • Mar 2007 - Feb 2009

  Monitored and analyzed HCI (Edit Management) by creating appeal responses to providers. Worked as a liaison between HCI and Molina for claim resolution or projects.Processed claims through AIM to ensure proper processing of claims, coordination of benefits leads, and made proper adjustments due to Molina/AIM recoupements. Trained adjustment team of AIM processes.Conducted audits for special projects for management due to under or overpayments due to configuration. Reseached MDCH guidelines & updates that would affect these projects.Researched and reprocessed UM appeals that had updates with authorization.Conducted administrative appeal reviews for past filling limit inquiries.Completed provider representative reviews that were high priority, COB issues, state complaints, and conducted meetings with Management regarding these updates. Show less

• LEAD COORDINATION OF BENEFITS

  • Jan 2002 - Mar 2007

  Assisted with assembling Molina's COB Department with management. Created policies and procedures for the COB Department.Trained all new employees, monitored production and reviewed for quality assurance. Conducted special projects for Management with COB issues.Complied high dollar reports for early recoupements.Resolved calls from providers and members with COB updates and inquires for COB group that required elevation. Verified primary insurance coverage, added alerts and notified the state medicaid of any updates. Identified all claims to be processed or recouped. Completed AIM recoupements & reports. Show less