Associate III BPM

• Apr 2022 - Present

Medical Claims Examiner

• Apr 2020 - May 2021

● Gain and maintain understanding of the plan designs and effectively apply that knowledge. ● ● Managed large volume of medical claims on daily basis. Used administrative guidelines as resource or to answer questions when processing medical claims. ● Maintained knowledge of benefits claim processing, claims principles, medical terminology and procedures and HIPAA regulations. ● Paid or denied medical claims based upon established claims processing criteria. ● Gain and maintain understanding of the plan designs and effectively apply that knowledge. ● ● Managed large volume of medical claims on daily basis. Used administrative guidelines as resource or to answer questions when processing medical claims. ● Maintained knowledge of benefits claim processing, claims principles, medical terminology and procedures and HIPAA regulations. ● Paid or denied medical claims based upon established claims processing criteria.

Claims Adjuster/FNOL

• Jun 2019 - Dec 2019

Assist USAA members with FNOL - the initial report made to the insurance provider following a loss, theft or damage of an insured asset. Assist USAA members with FNOL - the initial report made to the insurance provider following a loss, theft or damage of an insured asset.

Configuration Anyalyst II

• Feb 2019 - Jun 2019

Build rules situation with the Peradigm System, in coordination within State and Federal Guidelines ●Monitors and tests the accuracy of price rules● Builds and tests contracts and pricing templates for the non-par and new business teams ● Resolves provider load issues within appropriate time● Loads professional contracts into the Diamond system through appropriate research and provider data load activities ● Xcelys, FACETS, AMISYS, DST Pricer● Configured medical contracts in claims adjudication/pricing system● Prepared test cases and conducted User Acceptance Testing of Fee Schedules and payable procedure code formed testing and implementation of required health plan benefits and payment structure changes Interpreted and configured provider contracts, tested payable procedure codes and fee schedules in Facets 5.10 ● Resolved System Edits and Claim Workflow issues● Support client configuration changes and new configuration requirements, including configuration analysis design, build and test. Show less

Claims Adjuster

• Oct 2018 - Jan 2019

Medical Claims/Configuration Analyst

• Nov 2017 - Oct 2018

Correctly coded and billed medical claims for various hospital and nursing facilities ● Determined prior authorizations for medication and outpatient procedures ●Resourcefully used various coding books, procedure manuals and on-line encoders ●Posted and adjusted payments from insurance companies● Researched CPT and ICD-9 coding discrepancies for compliance and reimbursement accuracy ● Confidently and adeptly handled claim denials and/or appeals● Actively maintained current working knowledge of CPT and ICD-9 coding principles, government regulation, protocols and third party requirements regarding billing ● Assist with preparation with business requirements and configured claims focusing on tables, payments, Service ID, Service Definition, Service Rules and conducted detailed system analyst configuration ● NetworX configuration● Excel-VLOOKUP and Pivot Tables● Precisely completed appropriate claims paperwork, documentation and system entry ● Utilizing Facets processing Show less

Recovery Specialist/Data Ana

• Jan 2012 - Jan 2017

Responsible for identifying, tracking and reconciling overpayment made to providers and ensuring that recovery is made and reported. Processed hospital and skilled nursing facility claims via Medicaid following the State guidelines per assigned States ●Processed physician, Outpatient claims per Medicare following the federal guidelines● Perform authorized duties in the processing of of overpayment allocated to all assigned markets consistent with the applicable company and departmental policies Respond to calls, letters and emails from agents, vendors and/or Provider disputes ● Maintain working knowledge of all company products and services pertaining to business ●Work with Health Plan regarding overpayments/Provider disputes● Communicate with providers regarding overpayment disputes● Adhere to company and department policies and procedures as well as HIPAA regulations ● NetworX pricer/Configuration● Amisys● Perform other duties as requested or assigned - systems (Compass & Contact Logs) FACETS for all markets ● SPECIAL TEAM TESTER - Provided detailed analysis using Microsoft Access queries, troubleshooting and correcting issues utilizing Microsoft Access, SQL and Excel. Reporting and updating Facets data to ensure proper configuration process ● Process Encounter information based on Capitation Methodology● Show less

Credential/Provider Services

• Jan 2011 - Jan 2012

Assist in incoming calls explaining claim denials and provided payment information as well as benefit coverage information for members. Assist in incoming calls explaining claim denials and provided payment information as well as benefit coverage information for members.