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Work experience

June 2017July 2018

Claims Adjustment Analyst

United Health Group
  • To review and research  claims by navigating multiple computer systems and platforms and accurately capturing the data/information necessary for processing.
  • To complete reports on a daily basis while maintaining all data entry required to document and communicate the status of claims as needed adhering to all reporting requirements
  • To review medicaid related claims and to execute them according to their corresponding benefit plan and contractual delegated amounts.
  • To review medical records and provider agreements in accordance to corresponding denial or approvals.
  • To work as a individual contributor and to follow and to adhere to the rules and regulations implemented by medicaid and other assigned states.
  • To analyze and to execute multiple projects from excel into multiple databases to ensure proper reporting and regulatory standards are met.
  • To review appeals based requests in accordance with the  corresponding medical records and authorization requirements.
  • To compose appeals based requests in accordance with medical necessity based criteria as specified per the correlating  fee schedule.
  • To review appeals and make determinations on timely filing, contractual allowances and medical necessity and coding based issues.  
October 2016June 2017

 Clinical Coordinator

United Health Group
  • To  analyze inbound calls such as provider  inquiries and claims questions.
  • To process and analyze calls in regards to authorization requirements such as inpatient stays and behavioral health cases.
  • To utilize decision trees in accordance with the authorization requirements and the company guidelines and regulations to approve or deny clinical cases.
  • To process incoming member requests for dedicated accounts including benefit changes and contractual agreement inquires as well.
  • To process all faxes including explanation of benefits and policy changes and authorization approval letters and correspondents to providers and members in accordance with company policies and procedures .
  • To process  and execute inquiries for the plan such as claims inquiries and payment amounts and even provider contracting  payments.
  • To process any changes to providers remittance  information for payment purposes. 
  • To review clinical cases to make determinations for extended authorization needs and medical necessity   based needs.
  • To analyze an review incoming appeals requests in accordance with the benefits plan and  contractual allowances.
  • To review and execute appeals in accordance with established guidelines and procedures. 
April 2016October 2016

Behavioral Client Relations Analyst

Blue Cross Blue Shield
  • To field inbound calls related to complex benefit infrastructure maintenance and benefit inquiry analysis.
  • To field inbound and outbound calling for provider and patient based outreach programs to ensure proper care coordination is achieved.  
  • To route cases appropriately pursuant to the workflow for clinical review or to other departments as necessary.
  • To process or pend for clinical review certifications/authorization requests according to established policies and procedures from the work queue. To select contract eligibility, as it relates to prior authorization and/or referral authorization requests based upon information provided by hospital personnel, members, and providers.
  • To review/respond to service requests from incoming calls, faxes/Images, recorded voicemail messages from hospitals, providers, and members.
February 2015April 2016

Mutual Funds Analyst

State Farm
  • To field inbound calls  to ensure client based account maintenance and account analysis needs are met in accordance with established policies.  
  • To execute financial reporting measures by 95 percent reducing the amount of escalated cases assigned.
  • To field outbound calls to agent and staff members to ensure client based relationships were maintained and product education was aligned with corporate standards. 
  • To field inbound calls to agents and office leaders to ensure book of businesses were maintained in accordance with federal laws and company policies.
  • .To execute complex escalated support functions through virtual meetings and follow ups in which eliminates 50 percent of case management issues.
October 2014February 2015

Customer Service Supervisor

Burlington Coat Factory
  • To plan and coordinate multiple tasks throughout the day to ensure all associates are at maximum productivity.
  • To ensure that each associate is adhering to scheduled breaks and lunches accordingly.
  • To supervise each associate and to ensure that all tasks are completed by each associate by the end of work day.
  • To prepare the daily schedule for each associate according to policies and procedures.
  • To ensure that each customer service associate is delivering an exceptional customer service experience.
  • To ensure that all metrics and customer service surveys are being met on a individual basis and store wide basis.
  • To communicate with other departments and management to resolve problems and expedite work.
  • To resolve complaints and answer questions of customers regarding services and procedures.
October 2013 March 2014

Team Lead

Connextions 
  • To analyze client issues and implement solutions that are client specific according to established modules.
  • To provide exceptional customer service at all points of interface. To process multi-step transactions in accordance to established guidelines.
  • To review pharmacy insurance claims and to assist in correcting escalated issues.
  • To  provide account management support to front line staff in relation to escalated issues and case management inquiries. 
  • To provide coaching and call support to associates in accordance with established procedures.
  • To monitor and evaluate agents on quality assurance measures and practices and procedures in accordance with company guidelines. 
  • To monitor productivity standards of all team members and to make business determination in accordance with business needs.
  • To implement action plans and performance evaluations based on annual performance review requirements.
  • To conduct meetings and calibration sessions to improve training and development among front line staff. 

Education

June 2017Present

Bachelors of Science in Public Administration

University of Phoenix

Current

August 2015June 2017

Associates of Arts  in Healthcare Administration

University of Phoenix

Graduated: June 2017

August 2009May 2012

High School Diploma

Sherman High School

Graduated: May 2012