Traci Smith

Stockton, CA *****

Cell: 925-***-****

ad1tzq@r.postjobfree.com

Summary

Claims Recovery Analyst seeking a part-time position. I am a proactive leader with strengths in communication (verbal and written), organization, typing and Customer service. Proficient in problem solving and prioritizing. Adept at managing concurrent objectives to promote efficiency and influence positive outcomes.

Skills

Strong oral and written communication skills

Effective organizational skills and the ability to prioritize

Knowledge of CPT and ICD 10 codes

10 key by touch

Independent problem solver and decision maker

Thorough knowledge of claims adjudication processing procedures

Works independently as well as part of a team

March 1996-

to current

Claims Recovery Analyst

Altais Heath Solutions FKA Brown & Toland PSO

Oakland CA

Research claim overpayments, recoveries and related appeals, work with internal and external stakeholders to facilitate claims recoupments, and process all identified claims overpayments within regulatory and/or contractual timeframes. An understanding of claims processing requirements, which include, but not limited to interpretation of contracts and benefits, correct claims coding and billing. Communicate claims overpayment root causes and issues that impact claims processing to quality leaders. Demonstrate strong oral and written communication skills, professional approach to problem resolution, strong organizational skills with the ability to prioritize projects and strong financial analytical skills with attention to detail.

Claims Quality Assurance Auditor

Brown & Toland PSO

Oakland, CA

Perform routine and moderately complex audits and analysis on claims to identify inaccurate claims adjudication. Run and audit focused audit reports daily. Research claim processing problems and errors to determine origin and appropriate resolution. Summarize findings and recommendations in reports for feedback to Claims Representatives and Management. Participates in communication with Claims department management regarding results of claims audit process in order to improve claims processing accuracy. Track quality of claims processing and logs data into various spreadsheets. Ensure claims adjudication is in accordance with State, Federal and Health plan regulatory requirements as well as departmental guidelines. Provide initial claims processing training for Claims Representatives. Provide qualified data for incorporation into training programs, policies and procedures. Provides technical assistance on special projects, utilizing ability to interpret claims policies, including analysis and functional testing.

Assist with potential claims recoveries, offsets and Cogitativo recovery appeals.

Provide guidance to others with respect of complex claims. Provide root cause qualitative analysis of processed claims. Collaborate with other Brown and Toland departments to ensure the delivery of expedient, efficient and cost-effective service. Interfaces with various levels of internal and external personnel (i.e. UM, Claims, BAC, vendors to develop and maintain effective rapport and to resolve issues and inquiries.

Claims Adjustment Lead

Brown & Toland PSO

Oakland CA

Responsible for researching claims issues requests received from various customers (i.e. Customer service, Provider relations, Special projects, Service desk tickets, internal claims reports) - processes adjustments as needed and seek resolution when applicable. Additional responsibilities include working Cap deducts received from various health plans and researching necessary documentation and apply claims policy appropriately and accurately in order to resolve issues. Able to multi-task, route claims to the appropriate departments for handling, managing TAT on claims that have been routed to other departments. Accurately respond to inquiries on B&T policy regarding, claims status and adjustment requests. Works with other B&T departments in the resolution of all requests and inquiries in a timely manner. Tracking, distributing and monitoring of all inquiries and appropriate follow-up. Assist with potential recoveries.

Claims Examiner II

Brown & Toland PSO

Oakland CA

Responsibilities include understanding Plan Documents to determine benefits, researching claim history for duplicate claims, routing claims to appropriate departments to accurately resolve the claim and researching more complex claims to determine payment, with reasonable independence. Additional responsibilities include answering technical questions and provider calls.

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