Prior Authorization Utilization Management
Resume:
DOROTHEA CARTER
Southgate, Michigan ***** 313-***-**** ********-******@*********.*** https://www.linkedin.com/in/dorothea-carter
SUMMARY
A highly skilled and detail-oriented claim processing professional with a solid background in claim processing in Medicare and Medicaid, coordination of benefits, third party liability, and utilization management. Leverages excellent critical thinking skills to liaise between members and providers, ensure accurate and appropriate claims, and review / correct discrepancies. Utilizes an extensive background, knowledge, and professional skill set to serve as a key contributor to the on-going success of a company.
EXPERIENCE
HAP EMPOWERED CLAIMS DEPARTMENT, Troy, Michigan
Claim Processor II, 2015-2023
Coordinated with credentialing department to verify that all providers claims were adjudicated according to contracts and to ensure any discrepancies were corrected.
Received claim appeals and / or complaints and investigated circumstances and researched applicable laws, rules, regulations, and policy.
Reviewed prior authorization for diagnostic services, outpatient care, skilled nursing, inpatient services, and behavioral health services.
Ensured healthcare services required prior authorization and if it was medically necessary / appropriate for adjudication.
Conducted research online to Medicare to ensure accurate guidelines were followed to obtain payments on claim items.
Produced and reviewed member / providers finalized explanation of benefits (EOB) before issuing appropriate payment to all parties.
Priced, processed, and submitted Medicare and Medicaid claims electronically for payment according to state rules and regulations.
Examined and analyzed coordination of benefits (COB) by investigating coverage and determining payer priority to maximize recovery revenue.
HAP MIDWEST, Dearborn, Michigan
Claims Analyst II, 2008-2015
Processed claims forms, adjudicated allocation of deductibles and copays, and followed through with adjudication policies to facilitate proper payment.
Reviewed and verified patient account information against insurance program specifications.
Acknowledged and enforced confidentiality in alignment with Health Insurance Portability and Accountability Act (HIPPA).
Paid institutional / UB92 and HCFA claims based on providers contractual agreement and health plan reciprocity rates.
ADDITIONAL EXPERIENCE
OMNI CARE, Detroit, Michigan, Claims Analyst, 2001-2005. Verified eligibility and benefits. Processed HMO claims, assisted with answering billing calls from members and providers. Attached medical records, authorizations, and other required documents to claim cases. Ensured that timely filing limit was followed for all submitted claims.
EDUCATION
WAYNE COUNTY COMMUNITY COLLEGE, Detroit, Michigan
Associate of Arts, Business and Finance
TECHNICAL SKILLS
Facets PEGA Web Strat Process Workers’ Compensation Claims HMO claims Data Entry
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