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
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
- 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
- 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.