Medical Insurance

PAULA A NOVAKOWSKI HOME: 908-***-****

** ***** ***** **** ****:

908-***-****

Branchburg, NJ 08876 E-mail:

*********@***.***

OBJECTIVE

A highly motivated individual looking for a challenging career within the

insurance industry. Works progressively as part of a team and also

independently utilizing my skills and work experience.

WORK EXPERIENCE

Horizon Blue Cross Blue Shield Newark,

NJ

MTM Auditor

June 2008- April 2009

. Responsible for the completion of operational and procedural audits

directed towards assessing Horizon's performance with respect to the

established performance metrics such as performance guarantees and

BCBSA measures.

. Perform Claim, Inquiry (IVR, correspondence, portal and EDI) and

Enrollment (Group-Level and Member-Level) audits to determine the

accuracy of enrollment, plan payment and plan responses and to ensure

compliance with enterprise policies and procedures.

. Document identified defects from the initial receipt of the claim to

the final approval/notification of payment.

. Maintains records of all source documentation reviewed. This includes

but not limited to electronic raw data, provider contracts, pricing

information, and benefits.

. Performs analysis of various internal and external data to determine

accurate pricing for both institutional and professional claims.

. Interprets benefits by reviewing benefits to the original source

document.

. Conducts focused audits in support of management, customer, and

internal Audit department requests and provides feedback to reduce

errors and improve processes and performance.

Bollinger Insurance

Shorthills, NJ

Claims Examiner

September 1999-September 2007

. Processing Medical and Dental Claims

. Handling and Managing School Accident and Dental Claims

. Coordinating claims to and from provider discount networks

. Coding Medical Claims

Work Experience Continued

. Training Examiners

. Heavy phone contact for medical and dental claims questions

. Research and resolve policy issues with Company's Sales Producers

and

Underwriters on a day to day basis.

. Aides in formulating and answering letters for Appeals Determination

. Daily contact with Brokers, Employers, School Officials, Providers

and Insured

Dr Carl Voss DMD

Clinton, NJ

Dental Assistant/Office Manager May 1987-

September 1999

. Assisted in Dental Procedures

. Performed Dental Xrays

. Processed Dental Insurance Claims to Insurance Companies

. Coordinated monthly billings and collections

. Ordered all dental supplies and equipment

Somerset Medical Center Somerville,

NJ

Radiologic Technologist August 1985-

May 1987

. Performed Medical Xrays

. Worked in the Emergency Room performing Xrays

. Worked in the Operating Room performing Xrays

. Performed routine procedures such as Barium Enemas, Upper GI

Series, Mammography, Tomography, Etc.

Luzerne County Recreation Department Wilkes-Barre, PA

Recreational Counselor and Lifeguard June 1981- August

1985

. Life Guarded at a county owned pool

. Counselor for a recreation program for children and adults with

mental and physical disabilities

EDUCATION

College Misericordia

Dallas, PA

AAS Radiologic Technology August

1982- August 1985

Internship done at Mercy Hospital Wilkes-

Barre, PA

Internship done at Mercy Hospital Scranton,

PA

REFERENCES AVAILABLE UPON REQUEST

Contact this candidate