Claims Adjudication/Trainer

Wilma Staley

- TRIZETTO/COGNIZANT

Chandler, AZ *5224

*****.******@*****.*** - 678-***-****

Authorized to work in the US for any employer

WORK EXPERIENCE

Manager

TRIZETTO/COGNIZANT - November 2016 to Present

November, 2016- -Present

• Processing and adjudicating medical claims.

• Maintain integrity of claims receipts in accordance with standard claims operating and adjudicating procedures.

• Accurately resolving pending claims using state and federal regulations and specific healthplan criteria.

• Working within turnaround times to meet client performance guarantees for claims processing.

• Meeting productivity and accuracy standards.

• Adhere to specified TAT as defined by the business

• Complete special projects as assigned by Team Lead and Supervisor or Manager. Healthcare Representative

MCKESSON SPECIALTY HEALTH - November 2016 to November 2016

• Handling Inbound patient and physician calls; managing customer records using multiple computer systems;

• Multitasking in fast paced call center environment;

• Enrolling or re-enrolling patients in Novartis Patient Assistance Foundation

• Processing new prescriptions and re- filling existing prescriptions requests for patients and healthcare providers

• Maintaining and updating patient's records

• Verifying HIPPA requirements as needed with each caller

• Request shipping of medication to patients and health care facilities

• Tracking shipments as requested

Claims Examiner L2/Claims Examiner Trainer

Delta Dental Insurance - February 2008 to June 2016

• Train new hires on ESP (Enterprise) MetaVance system for CL1 & CL2;

• Created training materials; references for training classes which is now used Enterprise wide; part of the Enterprise Training Team and writes and updates ORL material

• Assist new and existing employees on a daily basis (CL1 & CL2) with claims issues

• Demonstrated processing procedures for the Pennsylvania office via satellite

• Assist Senior Coordinators with projects when necessary

• Perform special projects as requested by Supervisors, Manager and Director

• Review and update data from the Attending Dentist's Statement entered by Formworks into MACESS, which is suspended to different queues for processing

• Review vital information in queues retrieved from claims necessary to process claims

• Review and verify the accuracy of claim information; correct, change or deny according to description on certain diagnostic and basic procedures

• Research and amend erroneous or missing pertinent provider or member information necessary to process claims

• Trained new employees on Legacy System A

Associate Account Manager/Helpdesk Liaison

Reliance Trust Company - September 2006 to January 2008

• Managed Reliance's largest client servicing issues using state-of-the-art CRM application

• Supported SunGard's AddVantage Trust Accounting Platform

• Assisted account managers with various functions, supported client staff, and manage client access to online accounts

• Initiated transfer of cash and securities from previous or present trustee for new accounts

• Initiated transfer of securities to successor trustee for accounts terminating

• Daily review of the reports to verify status of asset movement and security positions at the DTC

• Changed registration codes to reflect the appropriate location and status of assets

• Post cash and securities transactions to accounts on SUNGARD/AddVantage system

• Post and monitor account transfers submitted via ACATS

• Ensured files are organized and written documentation is retained on transfers

• Initiate action to resolve any discrepancies with transfers; ensure that daily servicing activities are performed timely and accurately

Client Service Representative

Pilgrim's Pride Corporation - November 2004 to September 2006

• Lead client service representative for West Coast, Hawaii and Alaska regions

• Processed incoming customer orders, changes specified by brokers, sample orders, and donation orders

• Responsible for researching and resolving any invoicing issues

• Communicated with brokers, regional managers and division manager on shortages, invoicing questions, pricing issues, allocations, and national promotions

• Responsible for researching and resolving problems with transportation, dc and worked with production department on shortages

Accounts Specialist

- May 2003 to November 2004

• Created and maintained database for all distributors, loaded order information daily, Ran weekly and monthly reports to confirm order entry accuracy

• Prepared check requests for brokers involving military accounts

• Assisted distributors with any inquiries regarding payment, or product issues

• Contacted plants regarding military warehouse issues concerning product Assisted marketing manager

Welding Services, Inc - June 2002 to April 2003

in executing and maintaining website

• Assisted sales managers with remote computer issues

• Provided administrative support to the sales and marketing departments by preparing marketing correspondence and other material for meetings and seminars. ConAgra Poultry-Pilgrim's Pride

• Keyed financial data for Budget vs. Actual (Live Operation Reporting System)

• Performed special projects as requested by the Operations Controller at the Duluth Headquarters.

Supervisor of Administrative Services

Coventry Health Care of Georgia - June 1998 to May 2002 Supervised a staff of two, provided administrative support for CEO & Vice President of Operations

• Responsible for all travel and planning of senior level meetings, servicing the Board of • Directors, DOI Commissioner, CEO, Vice President, visiting employees and guests

• Prepared all travel expense reports and reviewed invoices for CEO & Vice President

• Information system liaison duties included setup of all new employees' workstations

• Installed software, hardware and performed QA testing

• Managed Georgia Office helpdesk

Network Management Rep1 Credentialing

Aetna-Human Affairs - April 1996 to June 1998

• Identified and recruited providers for the GA Network

• Prepared credentials for Credentialing Committee Review meeting

• Coordinated and developed training and educational material for providers

• Visited provider offices on a regular basis to ensure compliance prior to credentialing review meeting

EDUCATION

Associate in Office Technology & Business Communications Asher School of Business

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