Experience

Knoxville Pediatric Associates, P.C.

• United States
• Medical Practices
• 1 - 100 Employee

• Insurance A/R Representative and Benefits and Compliance Representative

  • 2011 - Present

  File pediatric medical claims to health insurance companies for processing and payment. Follow up on aging inventory. Research and resolve claims payment issues. Responsible for all employee medical and dental benefits, 401(k) enrollment, FMLA administration, Workers Compensation compliance. File pediatric medical claims to health insurance companies for processing and payment. Follow up on aging inventory. Research and resolve claims payment issues. Responsible for all employee medical and dental benefits, 401(k) enrollment, FMLA administration, Workers Compensation compliance.



Humana

• Brazil
• Professional Training and Coaching

• Claims Rework Specialist

  • Feb 2009 - Jan 2011

  Worked provider refund check issues. Determined if refund was appropriate and applied to provider accounts. Adjusted claims related to refund check to show correct benefit application. Monitored provider email requests with a 72 hour turnaround. Researched and responded to customer service claims status inquiries. Worked various reports and projects involving claims processed incorrectly. Assisted customer service by taking inbound calls from providers with claims issues. Worked provider refund check issues. Determined if refund was appropriate and applied to provider accounts. Adjusted claims related to refund check to show correct benefit application. Monitored provider email requests with a 72 hour turnaround. Researched and responded to customer service claims status inquiries. Worked various reports and projects involving claims processed incorrectly. Assisted customer service by taking inbound calls from providers with claims issues.



Cariten Healthcare

• United States
• Insurance

• Trainer

  • 2007 - 2009

  Trained new claims processors to work entry level claims. Created training manuals. Trained other employees on new software or processes. Maintained claims online work flow database. Wrote and revised work flow processes. Held bi-weekly meetings to address work flow issues. Took minutes and distributed copies to attendees. Audited claims audit staff to identify audit errors. Assisted claims department in inventory reduction. Trained new claims processors to work entry level claims. Created training manuals. Trained other employees on new software or processes. Maintained claims online work flow database. Wrote and revised work flow processes. Held bi-weekly meetings to address work flow issues. Took minutes and distributed copies to attendees. Audited claims audit staff to identify audit errors. Assisted claims department in inventory reduction.

• Configuration Specialist

  • 2004 - 2006

  Trained new claims processors to work entry level claims. Created training manuals. Trained other employees on new software or processes. Maintained claims online work flow database. Wrote and revised work flow processes. Held bi-weekly meetings to address work flow issues. Took minutes and distributed copies to attendees. Audited claims audit staff to identify audit errors. Assisted claims department in inventory reduction.

• Claims Supervisor

  • 2002 - 2004

  Supervised claims staff locally and in Chattanooga. Maintained claims inventory using aging and queue reports. Researched and corrected claims payment issues and provided feedback to management and other departments. Wrote work flows for claims processing. Led staff meetings and reviewed production and audit summaries individually with claims staff. Participated in URAC accreditation process.

• Claims Reprocessing Analyst

  • Jul 2001 - Aug 2002

  Worked service forms from customer service reps requesting review of claims processed. Adjusted claims as needed and returned service forms with detailed explanation of problem solution. Worked reports to address claims payment issues. Identified system configuration problems and communicated changes needed to configuration staff.

• Claims Auditor

  • Sep 1997 - Jul 2001

  Audited claims from multiple product lines for payment accuracy while maintaining required 45 audits per day and a turnaround time of 2 days. Entered audit results in database and ran reports for managment. Provided claims staff with audit results and met to discuss discrepancies. Trained claims processors on specific claim types to reduce inventory.

• Customer Service Representative

  • Apr 1994 - Sep 1997

  Answered inbound calls from insured members and providers regarding claims status and benefit issues. Documented calls in Macess system for tracking and training purposes. Identified claims processing issues and sent to appropriate departments for corrections. Returned calls with problem resolution.