Karnese T. Thornton Summary Qualification
**** ****** ***** **** **** 8 years experience as a Claims Analyst.
Road Extremely
Apartment D knowledgeable with regards to medical coding
Marietta, Georgia guidelines and coding
30067 techniques (ICD-9, CPT-4, HCPCS, and DRGs),
Cell: 706-***-**** proficient in physician
karnese.thornton@gmai coding, inpatient hospital coding, outpatient coding,
l.com and facility
Career Highlights coding. Strong knowledge of Anatomy and Physiology,
Eight years of Medical
quality performance Terminology, Psychology, and Pharmacology. Very
in claims, health proficient in using MS
plans Office Software, including MS WORD, EXCEL, POWER
processing/adjudicati POINT, ACCESS and
on and analysis OUTLOOK. Able to type 45-50 wpm and 350+dpm. Possess
leading to claim excellent
validation and interpersonal, organizational and time management
benefits assignments. skills, problem solving, analytical and communication
capabilities. Ability to work in a production
Achieved maximum environment and be goal oriented. Success in
results consistently developing effective relationships with multiple
every month: 100-110% individuals, and demonstrated multi-task
claim processing capabilities, including organizing, prioritizing,
rate; 98-100% working effectively under pressure, and operating
accuracy rate of autonomously with minimal to no supervision and
manual claims forms: direction.
HCFA 1500, CMS 1500,
UB-04, ADA-94,
Dental, EHER, Super Key Accomplishments
Bills, Vision,
Hearing,
Prescriptions and
DME/Home health.
Extensive knowledge
on health care
coverage plans and
products: HMO, POS,
PPO, Indemnity,
Federal, Medicare,
Medicaid, SCHIP,
TRICARE, VHA, FSA,
HRA, HSA, HDHP, CDHC,
third party payer
Awards
"Top Performance"
Award, 2002-2009
Impact Award, "No
Processing Errors"
for the year, 2005
"Service Excellence"
Awards, 2003-2009
Documented experience in Proficient in HIPAA
billing/ medical insurance Laws and Regulations
coding Knowledgeable in
Troubleshooting/ Problem Medicare/Medicaid
Solving Reimbursement
Technical/User Support Clinical Data Analysis
Assist in the development, and Extraction Expert
installation, monitoring and Knowledge of various
evaluation of claim systems health licensing,
and operations reimbursement and
Maintained databases of accreditation standards
medical providers and various
health networks
Professional Experience
August 2001-August 2009 Blue Cross Blue Shield GA,
Columbus, Georgia 31904
Business Analyst I (June 2009-August 2009)
Define, plan, coordinate and obtain information
requirements to support and launch new products and
software releases to maximize claims
auto-adjudication
Perform analysis for business applications,
researched and tested document issues
Responsible for loading and testing fee schedules,
including fee schedules from external sources
Responsible for claims payment edits and worked with
the claims staff to ensure accurate and timely claims
processing and adjudication (EDI: ASC X12 835 and
837)
Partner with the business and IT groups to find
solutions for project and operational issues
Translated business requirements to claim processing
staff to ensure that requirements were incorporated
into system design
August 2001-August 2009 Blue Cross Blue Shield GA,
Columbus, Georgia 31904
Senior Claims Analyst (August 2001-June 2009)
Understanding of health insurance applications,
benefit contracts, pricing (accounts payable) and
medical processing policies, procedures and medical
billing/coding (accounts receivable)
Adjudicated claims for assigned products; proof of
all claim submissions for required reviews from
various commercial insurance carriers including
Medicare and Medicaid, medical necessity, coverage
benefits, and cost containment to ensure appropriate
adjudication
Meet individual quality and productivity standards
for assigned claim adjudication function
Responsible for handling complex claim research
scenarios and serving as a technical resource to
colleagues on claim resolution of claim
pre-authorization and pre-certification issues and
similar situations requiring senior level expertise
Perform medical claim adjustments
Process claims in a timely manner
Outstanding customer service skills
Excellent knowledge and understanding of HIPAA laws
and guidelines
October 2000-August 2001 Total Systems, Columbus,
Georgia 31906
Customer Service Representative (October 2000-August
2001)
Develop and maintain knowledge to effectively
research and resolve "Customer Care Basics". The top
calls across several areas/calling queues
Complete/Conduct daily workload activities while
meeting and/or exceeding defined expectations of:
o Inbound call volume handling
o Quality of customer interactions
o Accuracy and Timeliness of Transaction Processing
Process requests and transactions in accordance with
bank policies and procedures of the Contact Center
Effectively utilize process and procedure manual,
bank sponsored trainings and software applications to
answer incoming customer inquiries
Education
Troy University, Fort Benning, Georgia (Major:
Business Administration, Minor: Computer Science)
2006-present
Chattahoochee Valley Community College, Phenix City,
Alabama (Major: Business) 2000-2001
Carver High School, Columbus, Georgia (Diploma:
College Preparatory Plus) 2000