Brenda S. Stratton

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

Indianapolis, IN 46226

Home Telephone # 317-***-****

OBJECTIVE

To secure a position that will utilize my extensive knowledge of the medical insurance industry and my customer service experience while offering an opportunity for continued growth and development.

ACCOMPLISHMENTS

Over twenty-three years experience working for one company in varied operational units, including Appeals, Fraud and Abuse, Claims Processing and Claims Adjustments.

Extensive knowledge of Medicare policies, medical terminology, ICD-9 and CPT coding

Participated in process improvement activites to evaluate claims processing flows, reduce appeals inventories, and eliminate complaint inventories

Requested by other units for assistance in reducing their inventories because of strong work ethic and ability to learn quickly

Received above average rankings on performance evaluations

EXPERIENCE

Nov 1984 -May 2008

National Government Services (Division of Wellpoint / Anthem BCBS handling Medicare contracts)

Claims processor III – Suspended Adjustment Unit 9/2006-5/2008

Responsibilities: Reviewed and finalized suspended claim adjustments initiated by other units including: Medical Review, Appeals, Business Systems Operations, Customer Service, and the Medicare Secondary Payer unit. Required understanding of guidelines for all those units (i.e., when Medicare is secondary to another payer), applying national and local Medicare guidelines, and familiarity with detailed mainframe systems to enter necessary codes and information to finalize claims. Also responsible for identification and referral of overpayments during the adjustment process.

Investigative Specialist- Fraud and Abuse Unit 7/2000-9/2006

Responsibilities: Investigated complaints of Medicare abuse from multiple sources, including beneficiaries, providers, customer service units and other external entities. Required outstanding customer service skills to effectively gather the facts from the complainants and the subjects of the investigations, as well as written communication skills to relay the outcome of the investigations. Often required provider education regarding correct billing practices, analysis of provider complaint trending, referral of suspected fraudulent activity for further monitoring and investigation, and referral of overpayments for recovery.

Appeals Counselor – Part B Appeals Unit 2/1992-7/2000

Responsibilities: Made decisions on customer initiated appeals of Medicare claim determinations (telephone and written). Required investigation to establish medical necessity for services, comparing medical documentation to national and local Medicare guidelines for payment. Maintained productivity and quality standards, and made recommendations to assist in reducing unnecessary appeals, including provider education and referral of high volume providers to Provider Outreach department.

Claims Processor – Part B Claims Unit 11/1984-2/1992

Responsibilities: Front and back end processing of physician claims for Medicare payment. Required data entry, knowledge of Medicare policy, ICD-9 and CPT coding, as well as working with complicated mainframe systems.

Skills/Training

Customer Service, Microsoft Word, Microsoft Excel, Fraud Tracking System; Mainframe systems (EDS, VIPS, MCS); Lotus Notes and Outlook e-mail software; Internet; PDF adobe files; Senn Delaney corporate culture training.

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