Customer Service Manager

**** ******* **. ********, ** ***** 347-***-**** *********@***.***

Tiusha Duckett [pic]

SUMMARY

Exceptionally accomplished Claims Specialist with 11 years' experience in

the

Healthcare Industry, including provider issues and claims resolution. Works

well with others or independently, proven ability to prioritize assignments

and shift focus when needs arise. Accomplished in managing numerous

responsibilities simultaneously in high-pressure environments.

EXPERTISE

. Project Management . End User Testing (UAT) . Training and

Development . Medical Terminology . Troubleshooting and

Issues Resolution . Networx Pricer . Encoder Pro .

Facets

EXPERIENCE

WellPoint, Brooklyn, New York

Grievance & Appeals Analyst

January 2014- August 2014

. Review,analyze and process non-complex grievances and appeals in

accordance with external accreditation and regulatory requirements,

internal policies and claims event requiring adaptation of written

response in clear, understandable language.

. Utilize guidelines and review tools to conduct extensive research and

analyze the grievance and appeal issue(s) and pertinent claims and

medical records to either approve or summarize and rout to nursing

and/or medical staff to review.

. Research and make determinations on complex appeals or grievances that

come from a variety of sources including state/federal regulators,

members, media, attorneys representing members and inquiries received

from any of these sources.

. Provide customer service to members that includes understand and

supporting cultural diversity of members

HealthPlus Amerigroup RealSolutions, Brooklyn, New York

Claims Research Specialist

May 2012- January 2014

. Research claims issues, inquiries, projects, and reconsiderations

related to claims. Including interpreting contract terms,

understanding system configurations, and knowledge of claims

reimbursement policies and medical coding

. Responsible for preparing correspondence to providers, maintaining

contact logs, project resolution for assigned market(s) and

communicating inquiry disposition to internal and external customers,

by way of letter, fax, e-mail or phone.

. Process all claim transactions as needed and audit pre-disbursement

high dollar claims and other specialized processes for accurate

payment.

. Review and respond to Quality audit assessments and Action Grams in a

timely manner.

. Investigate returned notification froms to determine reason for return

and perform complex claims adjustments.

. Communicate identified trends related to claims processing errors to

management

. Act as a technical resource and a mentor for claims associates

. Assist with the training of new associates and in conducting refresher

training as needed

HealthPlus - Brooklyn, New York

Claims Supervisor

November 2011- May 2012

. Reported to the Claims Department Manager. Responsible for supervising

all daily functions in the Claims Department and overseeing the Claims

Unit of 36 employees. Distributed all daily work whiles calculating

daily inventory and production statistics. Analyzed and adjudicated

all high profile and high dollar claims

. Maintained and managed the Manual Adjustment Log that entails all

projects directed to the Claims Department from various Departments

throughout the company.

. Analyzed and resolved complex claims, State inquiries (i.e.DOI, DOH),

Correspondence and Customer Focus cases referred for Supervisory level

review, ensuring accuracy.

. Completed Annual Performance Appraisals for Claims Staff and

Corrective Action Plans, ensuring Employees were aware of their

overall performance in several competent areas.

. Heavily Involved in User Acceptance Testing process for implementing

new and/or contract amendments into Facets; identify errors prior to

Production Implementation.

. Assisted claims staff including Quality Specialist and Correspondents

with various projects and questions in an effort to ensure accuracy.

. Worked closely with Claims Manager to coordinate mass adjustment

projects, which includes working simultaneously with various

departments such as IT-Development, Provider Relations, ASDI and ITS

OPS.

. Worked directly with Claims Manager on a variety of tasks with a wide

degree of creativity, problem solving skills and latitude

. Interacted with various departments on a daily/weekly basis (i.e.

Provider Relations, Outreach, Member Services, Health Services,

Behavioral Health and ASDI) to ensure aged claims are resolved and

finalized accordingly.

. Provided production analysis data in the Weekly Lag Report to Senior

Management, assisting in the monitoring of State Regulations.

. Performed special studies and handled special Projects at the request

of the Manager, or Director of Claims Administration ensuring

accuracy.

. Conducted interviews with potential candidates for any open vacancies

within the Claims Department in an effort to fill all vacant

positions.

. Interpreted Medical Policies to the Staff when necessary in an effort

to have claims adjudicated accurately reducing all Correspondence and

Customer Focus backlogs.

. Calculated Manual Diagnosis Related Groups and High Cost Outliers in

accordance to The Department of Health Methodology, based on Health

Plus's line of business, Healthcare Plus, Family Health Plus and Child

Health Plus.

. Heavily involved in iHealth's Professional and Outpatient Testing,

resulting in accurate production implementation

.

HealthPlus - Brooklyn, New York

Quality Specialist II

March 2007- November 2011

. Responsible for training new staff, existing staff as well as other

departments as needed.

. Responsible for auditing 2% of claims adjudicated daily for all Claims

department units including temporary data entry staff.

. Complete the Claims department Audit books on a monthly basis by

reporting detailed documentation of the error rate for each employee

and a summary of the overall departmental error rate for the month.

. Responsible for communicating errors to the staff verbally and in

writing as well as documentation verbal warnings for re-occurring

errors.

. Responsible for reiterating claims policies, procedures and workflows

via e-mail to Claims staff as well as updating and documenting new

policies, procedures and workflows.

. Respond to Department of Insurance complaints and all follow-ups to

have the case closed

. End User testing of amendments/contracts create test scripts

communicate findings via email and issues log. Post productions

testing to ensure claims are adjudicating according to the contract,

system or rate updates.

. Report to Claims Director in weekly meetings audit results and

specific concerns involving Claims staff, re-occurring errors and

current workflows.

. Respond to Department of Insurance Complaints (DOI)

HealthPlus - Brooklyn, New York

Claims Analyst

December 2005- March 2007

. Responsible for reviewing, analyzing and finalizing claims ensuring

payment/denial accuracy while adjudicating pended claims.

. Met and at times exceed departmental standards of adjudicating 60

claims per hour.

. Analyzed claims to determine member eligibility and provider

reimbursement for participating and non-participating providers.

. Reviewed and interpreted Claims Medical Policy Procedures, reviewed

provider refunds to determined appropriate adjustment workflows.

. Finalized complex claims and appeals including inpatient claims

requiring manual pricing and claims from reports requiring review from

ITS, Provider Relations, Outreach, Member Services and Health

Services.

. Assisted in reviewing post payment adjudication inquiries from

Customer Focus provider inquiries and Correspondence cases.

. Replied to various claims inquiries from various departments via

telephone and e-mail.

. Work on various adjustment projects assigned by Claims Supervisor

including providing a detailed summary of findings and resolutions.

HealthPlus - Brooklyn, New York

Claims Processor

January 2004- December 2005

. Responsible for data entry of paper claims including provider and

member information into the Facets database efficiently and promptly

ensuring provider satisfaction.

. Perform Provider selection on pended claims according to Claims

department workflows

. Verified member eligibility using MemberPro SQL application.

. Knowledge of industry coding and familiar with medical terminology

i.e. ICD.9, CPT, HCPCS. Utilized knowledge of coding to identify

inappropriate billing and ensure accuracy

References furnished upon request

Contact this candidate