Manager Supervisor

PAUL J. VAUGHN

**** ******** ***** • Los Angeles, CA 90043 • 323-***-****

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SUMMARY CLAIMS ANALYST possessing excellent analytical and communication skills

with the ability to manage multiple priorities and problem solve. Extremely flexible and result-oriented

with strong attention to detail.

EDUCATION HIGH SCHOOL OF ENGINEERING AND SCIENCE, Philadelphia, PA

Graduated, June 1986

STATE BOARD OF CALIFORNIA LICENSED PHARMACY TECHNICIAN (2005)

EXPERIENCE SHEET METALS WORKERS TRUST FUND, Manhattan Beach, CA 02/10-04/10

Claims Examiner

• Performed processing, examination, adjudication and adjustment of outpatient/inpatient professional

and facility claims using ISSI claims platform

ALL’S WELL STAFFING SERVICES, Pasadena, CA 02/09-01/10

Claims Examiner (Temp Position)

• Performed processing, examination, adjudication and adjustment of outpatient/inpatient

professional and facility claims using two step pricing methods

MOLINA HEALTHCARE, Long Beach, CA 01/05-08/08

Claims System Specialist, Claims Services

• Performed testing of contract and benefit configuration via claims processing for new and existing

health plans

• Testing of electronic claim submission validation and accuracy of system computation upon

implementation or creation of fee schedules for new and existing health plans

• Reported testing for new and revised reports used with Claims and used as a means of workflow

with other healthcare departments and/or plans

• System enhancements testing via claims adjudication

MOLINA HEALTHCARE, Long Beach, CA

Lead Claims Examiner, Claims Services

• Assisted supervisor in monitoring claim inventory and distribution of daily claim workload

• Interacted with key departments to resolve special claims issues (UM, Audit and Configuration)

• Actively supported supervisor/manager with reports, special projects, training of new

staff and communicated to claims team any new updates of claim guidelines

• Participated in teleconference calls with health plan and outside vendors regarding various claims

issues and contracting updates

• Conducted group interviews along with supervisor/manager for potential new hires

EXCELLERx, Philadelphia, PA 08/00 – 11/04

Pharmacy Technician, Special Business Unit

• Implementation and admission of new patients through interview process including

verification of third party coverage

• Profiling of new and current medications unique to palliative care and post-soft organ

transplantation

for pharmacist review

• Processing of refills and Federal Express shipment reconciliation

• Adjudication of claims and retrieval of prior authorizations

• Triaging of inbound calls within call center queues from nursing staff and patients

• Verification of state and DEA license for new physicians

• Completion of daily reimbursement spreadsheets forwarded to accounts receivable

• Reconciliation and filing of prescriptions (controlled and non-controlled)

TECHNICAL Windows 98/NT/XP, MS Word, MS Excel, MS PowerPoint, MS Access, XERIS, Quick Books, Great

SKILLS Plains

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