Medical Records
Resume:
L aBlonda McClinon
L i tchfield Park, AZ 85340
*********@*******.***
Experience:
M agellan Healthcare, (09/07 to 03/2008) - Phoenix, AZ
Data Validation Specialist: Conduct internal data validation audits of medical records
ensuring t imely, accurate, and complete submission. Analyze data, recommend
i mprovement strategies, implement approved change, and monitor sustainabili ty. Review of
behavioral health medical records to validate whether covered services are delivered to the
consumer and encounters billed to the RBHA for financial reimbursement. Review
P roviders medical records to identify suspected fraudulent billing practices, and insurance
p rinciples.
T riWest Healthcare Alliance, (11/05 to 01/2007) - Phoenix, AZ
Program In tegrity Analyst: Assist in identification analysis, case development and reports
of any suspected fraud or abuse. Analyze medical records; software applications,
summarizing findings and presenting them as appeals to payers, individually or as special
p rojects. Review patient's medical records encounters for clinical facilities and professional
services. Summarize findings and presenting them as appeals to payers, individually or as
special projects.
Affiliated Computerized Services, (06/2004 to 04/2005) - Tempe, AZ
Claims Auditor: Evaluate adjusters and medical processor production on PPO and
i ndemnity plans on medical, dental and Medicare claims. Provided support to medical
claims, t raining, plans. Assist in functional analysis processes and/or procedures support
t asks, referring to established policy, multi-task priorities, and claims and encounter,
member and eligibility, and provider data.
P rime Staff, (03/2003 to 03/2004) - (Maricopa Health) Phoenix, AZ
Claims Analyst: Review HCFA's, UB92's and dental claims. Manage and research the
corrective functions related to claims adjustments, reversals, refunds, COB/TPL, grievances
and special projects. Maintain production quality standards according to AHCCCS
regulation. Work with Medicare and Medicaid. Develop and maintain a work priority
system to ensure daily and make sure heavy loads are fulfilled. Identify configuration,
p rocess and billing issues: facilitate resolution.
Blue Cross and Blue Shield of Arizona, (03/1996 to 07/1999)-Phoenix, AZ
Claims Analyst II: Validate claims to ensure criteria, adjust HMO claims, and errors to establish
standards. Responsible for EDI claims which include paying and denying claims to various
payment systems, researching hospital financial/payer compliance software.
EDUCATION:
08/1996-10/1999 Glendale Community College; Communications, Nursing- Glendale, AZ
04/1993-11/1995 Apollo College; Medical Assistant Certificate- Phoenix, AZ
08/1989-06/1992 Trevor Browne High School; Diploma- Phoenix, AZ
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