Upper level claims examiner handling medical claims up to $250,000.
- Medical Claims Examiner at GEICO
- Front Desk Supervisor at Performance Spine & Sports Medicine
- Assistant Sales Manager at Hampton Inn
- Guest Services Agent at Hampton Inn
1 year, 9 months at this Job
- Bachelor of Science - Communication Studies
May 2018 to October 2018
• Processed medical claims for Union Health and Welfare Plans
• As a Blue Cross Blue Shield affiliate their guide lines for processing were used for claims adjudication with in Facets. Including the utilization of Blue Squared for Host claims processing Unified Life Insurance Company March 2015 to December 2016
• Processed personal lines for all states adhering to state and contract mandates
• Processed Medicare supplement plans
• Researched medical records related to pre-existing conditions
• Resolved overpayments and adjustments. Utilized "Aldera" software Dell/Perot Systems February 1994 to Januaryl 2010
• Served as claims examiner, quality control analyst, and special projects analyst
• Examined 70 to 100 claims daily, depended on type and complexity of claims and processing systems required
• Assisted peers, as team lead, in handling difficult claims and daily/weekly project issues
• Investigated improperly-processed claims and reworked them to determine cause of errors
- Medical Claims Examiner at Toshiba International Corporation
- at The Jacobson Group
- at Broad Path Healthcare Solutions
5 months at this Job
I reviewed medical claims to determine eligibility and validity. In this position, I was required to maintain confidentiality and handle confidential information. I was in charge of analyzing the claims that were assigned to me and to document all actions.
- Medical Claims Examiner at Sedgwick Claims Management Services
- Dedicated Service Representative at Medline Industries
- Customer Service Representative at Medline Industries
- Food Server at Texas Roadhouse
10 months at this Job
- - General education
- - nursing and psychology
San Jose, CA Dec. 23 2013 - Current Responsibilities: Establishing and maintaining a high level of productivity. I work in one software application called Qnxt, where I manage my work load for product lines such as, Medi-Cal and Commercial for Santa Clara County. The Medi-Cal line of business incorporates: Medi-cal, Healthy Kids and Healthy Family. The Commercial line of business includes Employer Group. I ensure coverage, benefits, authorizations, and adjustments are properly entered and correct. I track that system is paying correct rates for various provider specialties. Assuring all claim information is entered into system accurately to certify prompt payment from VHP to contracted Providers in a timely manner. I research to resolve difficult claim issues (eob not matching, possible LOA, Providers not in our system). Accountable for mailing out appropriate denial letters to contracted and non-contracted providers as to why their claims have been denied, or if additional information is needed. In addition I have been responsible for all Provider's not found in Qnxt. I assist Provider Relations Department in requesting all information needed to enter a new Physician into the system. (W9, Tax Forms, 590 etc.) I generate and maintain daily, weekly and monthly logs as directed for various projects. I annotate any and all changes, returns, adjustments and all send backs for correction.
- Medical Claims Examiner at Santa Clara County - Valley Health Plan / Claims Department
- Medical Claims Examiner Data Entry at Valley Health Plan / Claims Department
- Customer Service to Accounts Receivables Department at Therosedress.com
- Administrative Assistant to accounts receivable and front office at Pscan Imaging
5 years, 1 month at this Job
- - Medical Insurance Billing and Coding
- Diploma - High School Diploma
• Consistently meet established productivity and quality standards to guarantee timely, well organized and precise claims processing.
• Analyze claims for possible fraud.
• Exceed expected quota of claims processed accurately while assuring 95 percent accuracy rate.
• Resolve medical claims by approving or denying documentation; calculation of benefit due; initiating payment or composing denial letters.
• Determine covered medical insurance losses by studying provisions of policy.
• Protects operations by keeping claims information confidential.
• Research each claim and paid according to specified benefit contracts.
• Provide expertise and general claims support by reviewing, researching, investigating, processing and adjusting claims.
- Medical Claims Examiner at Silverback TPA
- Subrogation Claims Specialist at Allstate
- Billing-Customer Service at Baylor Scott and White
- Auto Finance Customer Service Specialist at JPMorgan Chase & Co
1 year, 7 months at this Job
- Bachelor of Science - Business Administration
• Process outpatient /inpatient claims for providers and members
• Evaluates, examine and adjudicates claims pended by system due to contractual or payment discrepancies by reviewing description of services on claims related to outpatient/inpatient and medical claims. Refer claims denied to medical review consultants for medical necessities.
• Identified potential claims problems and recommended methods to improve to boost system
• Efficiency to management.
• Identified need for new messages to clarified the explanation of benefits
• Verified and updated information related to submitted claims, authorizations and work flow processed to determined reimbursement eligibility
• Analyzed claims and report billing discrepancies to overpayment, underpayments, retroactive
• Termination errors, duplicate billing and coding errors.
- Senior Medical Claims Examiner at Aftra Health Retirement Fund
- Maryland Insurance Group Medical Claims Examiner at
22 years, 7 months at this Job
- Bachelor of Science - Business Administration
Appropriately coded medical claims to insure correct reimbursement.
- Medical Claims Examiner at FirstSource
- Cashier at Schnucks Markets, Inc
- Technical Support Supervisor at Alorica, Inc
- Retail Wireless Consultant at U.S. Cellular Corps
8 months at this Job
Responsible to review all medical claims, customer service to members and providers, negotiations, understand and administer of several Local Welfare Funds policies and coverage. Data processing of claims for timely payments as well as several other administrative functions as requested by Supervisor and Managers.
- Medical Claims Examiner at Basil Castrovinci Associates
- Administrative Assistant at Miller Diesel Service
- Dental Assistant at Dr. Ann Kirk
- Receptionist at David J. Porzio
8 years, 9 months at this Job
Working with Blue Cross Blue Shield Medicare Advantage products through the following states: WA, NE, AR, FL claims. Processing and Adjudicating medical claims through the Medicare Advantage platform. Handles routine questions and issues, assisting with complex or unexpected matters. Checks for completeness and appropriateness of source data. Involved in fact finding, information search and data gathering. Verifies and compiles data. Identifies and resolves routine and recurring problems. Provides solutions and alternatives to ongoing issues.
- Medical Claims Examiner at NTT DATA Services
- Radiology Office Lead - Access Services/Patient Access at Baylor Scott and White
- Resolution Support Specialist Tier 2 at United Healthcare
3 months at this Job
- A.A.S - Health Sciences
- High School Diploma - Aleasha Brooks
Review and process medical claims, handle the coordination of benefits between the company and any other coverage the member might have available, including Medicaid or private insurance.
- Medical Claims Examiner at Corizon Health
- Staff Accountant at AMERICAN INTERNATIONAL GROUP
- Actuarial Assistant at AMERICAN INTERNATIONAL GROUP
- Claims Analyst, AIG at AMERICAN INTERNATIONAL GROUP
2 years, 4 months at this Job