PAULA OFLYNN

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TAYLORSVILLE, KY 40071

502-***-****

I RECENTLY RETIRED FROM HUMANA INC. I HAD A CAREER WITH HUMANA FROM JANUARY 1988 UNTIL NOVEMBER 2015. I WORKED IN MANY DIFFERENT AREAS.

I STARTED IN CLAIMS AND WORKED

MY WAY UP TO LOADING CONTRACTS, GRIEVANCE AND APPEALS, AUDITING. I WAS ABLE TO TEACH CLASSES TO NEW ASSOCIATES AS WELL AS SEASONED ASSOCIATES.

JANUARY 1988-1995

CLAIMS PROCESSOR DUTIES WERE TO ANALYZE CLAIMS DETERMINATION EXTENT OF COMPANYS LIABILITY, MAKE APPROVAL OR DENIAL DECISIONS

CONTRACT LOADING FROM 1995 TO 1997

CONTRACT LOAD: LOADED CONTRACTS IN SYSTEM FOR HMOS,PPO,MEDICARE FOR OUR SYSTEM TO CORRECTLY PAY OUT BENEFITS.

AUDITOR FROM 1997 TO 2013

AUDITING-CORRECTED ALL OR ANY DATA ENTRY ERRORS SUCH AS DIAGNOSIS CODE, DATES OF SERVICE,MAKING SURE MEMBER WAS EFFECTIVE AT THE TIME OF SERVICE AND MAKING SURE THEY HAD PRIOR AUTHORIZATIONS OR WAIVER NEEDED AND ADJUDICATED THE CLAIM CORRECTLY WHETHER TO BE PAID OR REJECTED.

GRIEVANCE AND APPEALS FROM 2013 TO 2015

GRIEVANCE AND APPEALS- REVIEWED CLAIMS THAT WERE PREVIOUSLY REJECTED FOR PRIOR AUTHORIZATION, WAIVERS, EFFECTIVE DATES, INDEPENDENENTLY CONDUCT THOROUGH INVESTIGATIONS OF ALL MEMBER AND PROVIDER CORRESPONDENCE BY ANALYZING ALL THE ISSUES INVOLVED AND OBTAINING RESPONSES AND INFORMATION FROM INTERNAL AND EXTERNAL ENTITIES,PREPARED WRITTEN RESPONSE AND DETERMINATION LETTERS THAT APPROPRIATELY ADDRESS THE ISSUE AND THAT MEET ALL REGULATORY AND REQUIREMENTS WITH REQUIRED TIME FRAME.

PRODUCE ROUTINE AND ADHOC REPORTS ON GRIEVANCES, COMPLAINTS AND APPEALS FROM THE GRIEVANCE AND APPEALS DATABASE

REFERENCES:

MEGAN CURTIS-HUMANA-502-***-****-GRIEVANCE AND APPEALS

TIFFANI RICHARDSON HUMANA 580 1000-GRIEVANCE AND APPEALS

Rhonda Schmeltz - HUMANA 502-***-****-SUPERVISOR

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