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Supervisor Medical

Location:
Cordova, TN, 38016
Posted:
September 08, 2010

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Resume:

Ora James-Lewis

**** ********** *****

Cordova, TN 38016

Home#-901-***-****

Cell#-901-***-****

SUMMARY OF QUALIFICATIONS

Experienced Managed Care Administrator with 6 years focus in supervision.

Responsible and adept to meeting the need of all parties involved with

favorable results. Able to solve problems by analying the facts and taking

the initiativeness to proact. Meet challenges with a positive and

professional attitude. Skills include:

Microsoft Office ; Customer Focus; Diamond Claims

Management System; Med Value; Clear Claim Connection and Citrix.

PROFESSIONAL EXPERIENCE

AMERIGROUP CORPORATION (dba TLC Family Care Health Plan) Memphis

TN

Claims Supervisor(11/01/2003-11/1/2009)

Supervised 13 member Claims Adjudicator Unit Staff including hiring,

recommendations,terminations,and discipline.

Set work properties according to weekly and/or daily backlog goal.

Monitored employee daily production.

Evaluated annual work performances and recommend salary increases.

Identified new claim processing problems and referred them to appropriate

personnel for guideline or policies to be established.

Resolved provider call-in issues and/or concerns.

Researched, and resolved via written communication TennCare State

Provider/enrollees appeals and complaints.

Ordered staff members supplies and reference materials.

Acted as a Staff Specialist for all company new hires by presenting an

overview of the claims department functionality.

Assisted with departmental development of policies and procedures.

Released high dollar claims.

Processed claims when necessary.

Selected out of 46 associates to close out TLC business operation.

Other Party Liability Administrator (09/12/1994-10/31/2003)

Communicated, maintained and enforced other Party Liability policies and

Procedures(i.e, coordination of benefits and subrogation).

Investigated and updated other Party Liability files.

Educated TLC Employees on Other party Liability policies and procedures.

Reviewed and resolved claims routed for other Party review.

Submitted catastrophic claims to our Reinsurance provider for

reimbursement.

Collected and recorded all Reinsurance reimbursement checks.

Provided weekly Other Party Liability reports to TLC management staff and

to the

TennCare Bureau as necessary.

Claims Adjudicator II (1/1/94-9/11/1994)

Entered and adjudicated claim data for medical claims as related to the

negotiated contract.

Adjudicated medical claims where members had other primary health

insurance.

Adjusted claims denied, overpaid and/or underpaid in error.

Met and maintained minimum production and quality standards for a Level II

Adjudicator.

Handled more difficult and complex claims and specialized accounts.

TRAINING

Certificate in Clerical Administration at Memphis Area Vocational Technical

School. Supervisor Certification.



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