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Danielle A. potts

Claims Analyst Representative

Work History

July 9, 2018Present 

Claims Analyst Representative 

Health Plan of Nevada - United Health Group - Las Vegas Nevada 
  • Effectively analyzed and coordinated benefits for payments on health claims.
  • Processed coordination of benefit claims.
  • Maintained the company's production and quality standards.
  • Precisely evaluated and verified benefits and eligibility.
  • Investigated medical records to determine pre-existing medical conditions.
  • Performed other office duties as needed.
  • Denied all incorrect claims submissions.
  • Reviewed medical claims submitted as an appeal.
  • Researched each claim and paid according to specified benefit contracts.
  • In-depth knowledge of medical insurance and medical terminology.
  • Ensure the coverage and figure the payment amount for each claim.
  • Ability to understand insurance contracts.
  • Proficiency with computer platforms and applications.
  • Knowledge of COB & EOB. 
  • Ability to process Professional & Facility Claims.
  • Knowledge of Facets and Macess Medical Platforms.
June 12, 2017July 6, 2018

Patient Services Advocate

Southwest Medical Associates - United Health Group - Las Vegas, Nevada
  • Achieved performance evaluations for call handling ability and quality of services provided to patients in a fast paced, high volume call center.
  • Assisted patients with all aspects of insurance billing resolution or payments and documented any information or conversations in the computer regarding the patient's accounts.
  • Understand the importance of dealing with confidential information.
  • Resolved problems or escalated to managers as needed -able to diffuse intense situations and frustrated callers.
  • Provided information regarding patient accounts to authorized callers while complying with HIPPA guidelines and regulations.
  • Verified and updated patient demographic information and insurance information.
  • Scheduled and rescheduled appointments in person and via phone.
  • Scheduled appointments and referrals from other medical offices.
  • Monitored work queues to ensure information was complete in EPIC HIS system.
  • Assisted in the referral process such as faxing referrals and scanning related documents.
  • Completed daily reminder calls to patients regarding upcoming appointments.
  • Interacts with members of the professional staff and ancillary personnel while acting as liaison between physicians, nurses and patients. 
  • Identifies whether patient needs authorization or referral.

Medical Systems 

  • AYS-At Your Service
  • Genesis soft phone system
  • Touch-Works
  • Centricity
  • IDX
  • Microsoft - Excel, Power Point and Word.
September 12, 2016June 6, 2017

Pharmacy Prior Authorization Specialist for Workers Compensation

Optum Rx - United Health Group - Las Vegas, Nevada
  • Processing Workers Compensation Claims.
  • Manage inbound calls from insurance adjusters.
  • Manage inbound calls from major pharmacy's.
  • Authorizing medications, restricting medications, and doctors.
  • Processing prior authorizations to major insurance companies for decisions on medications.
  • Identifying medications and strengths, emailing various teams and insurance companies.
  • Evaluate and approve / deny adjuster requests to authorize medications. 
  •  Maintain productive working relationships and communications with all claim service providers and insurers on all aspects.
  • Ensure delivery of quality services and nurture positive employee/client relationships
  • Patient Benefits Verification
  • Patient Account/Claim Creation
  • Receive and verify requests for prior authorizations and ensure that they are administered properly
  • Verify Medications
  • Medication Authorization Processing

Education

19941999

High School Diploma

Benton Harbor High School

General Studies Diploma

20122014

Hospitality Administration 

Ivy Tech Community College

Knowledge Of Hospitality Field 

Skills

Customer Service Skills 
  • Advance Customer Service skills,
  • Inbound and Outbound Calls
  • Hard Phone and Soft phone
  • High Volume Call Center
  • Pharmacy Eligibility  
  • Member Benefits Eligibility 
  • Benefits Specialist
  • Seven Years of Customer Service/Call Center Experience
  • Payments and Services Support
  • Ability to multi-task, manage details and organize efficiently and effectively
  • Ability to listen compassionately demonstrating effective problem-solving and critical-thinking techniques.
  • Ability to prioritize,
  • Excellent typing and 10 key
  • Excellent written and verbal communications,
  • Able to communicate effectively with all levels of Internal & external customers
  • Ability to use relevant computer hardware and software, telephone, copier, fax machine and other standard medical office equipment
  • Strong team orientation
  • Ability to read, interpret, and apply policies and procedures
Leadership Skills - United Health Group/Optum Rx
  • Mentoring and Training a team of 5
  • Advising a team of 5
  • Assisting with daily work task
  • Answering various questions about my day to day process of duties
  • Coaching a team of 5
  • Listening to calls and advising 

Certifications

Jun 2013Present

Food & Beverage Supervision 

Ivy Tech Community College
I've passed all Academics to become certified to be a Food and Beverage Supervisor.
Jan 2013Present

Hospitality Human Resource Management and Supervision 

Ivy Tech Community College 
I've passed all Academics to become certified to be a Human Resource Manager in the Hospitality Field.  
02/2017Present

Leadership

Untied Health Group/Optum Rx

Leadership Resignation - For Training & Mentoring a Team of 5