Medical Insurance

Beverly Burks

Professional Summary:

Beverly brings over 15 years of claim processing experience in a variety of settings, including Managed Care

As a Senior Claims Examiner with Cigna, she adjudicated Medicare and commercial claims, followed up on the status of claims, and composed appeal letters for denied claims

She has experience determining accurate payment criteria for clearing pending claims, and meeting productivity goals, quality standards, and aging time frames

Professional Experience:

Cigna, Houston, TX

January 2002 – May 2014

Senior Claims Examiner

Processed Medicare and commercial claims, as well as Primary Care Physicians, Specialist, and Ancillary Provider claims

Followed up with Medicare on the status of claims, composing appeal letters including supporting documents to complete appeal for denied claims

Documents appropriately in Patient Accounting System as well as within Appeals and Denials databases

Processed a minimum of twenty (25) “Fee for Service “and “Capitated” specialist claims per hour

Maintained accuracy and production standard established for a claims examiner Aetna, Sugar Land, TX

October 2000 – December 2001

Claims Benefits Specialist

Adjudicated claims billed by Primary Care Physicians, Specialty Care Physicians and Ancillary Providers after system suspended them for information such as updating Medicare information, continuation of benefits, referrals and precertification

Determined accurate payment criteria for clearing pending claims on editing, and meeting productivity goals, quality standards and aging time frames

Interpreted and applied contracts, fee schedules and reimbursement methods for proper claims adjudication

Handled insurance verification, coordination of benefits,, explanation of benefits, customer & provider services, as well as CPT and ICD-9 Coding

North American Medical Management, Houston, TX

October 1998 – October 2000

Professional Claims Auditor/Claims Examiner

Adjudicated claims for Primary Care Physicians, Specialty Care Physicians and Ancillary Providers per IPA matrix guidelines for assigned IPA

Investigated and verified overpayment issues to be forwarded to Refund Coordinator, and recorded auditing results into claims accuracy database

Assisted with backlog of all IPA's, attended weekly team meetings while maintaining an overall claims processing accuracy of 98%

Completed claims and assured errors were corrected, and reported auditing results to examiners, examiner supervisor, and QA supervisor

Prudential Insurance Company, Sugar Land, TX

May 1997 – October 1998

Claims Examiner II

Administered claims for large corporate clients using HMO, PPO and POS services with several different plans and riders

Served medical insurance customers by determining insurance coverage, explaining billing, and resolving medical claim issues

Beverly Burks

Polly Ryon Memorial Hospital, Richmond, TX

June 1996 – May 1997

Non-Government Insurance Collector

Collected managed care, commercial, indigent and workers compensation claims

Assisted patients with account inquiries and mailed letters to patients and insurance companies Education:

Medical Assisting Diploma, National Education Center, Bryman Campus, South, Houston, TX High School Diploma, C.E. Byrd High School, Shreveport, LA

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