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.