Andrea Lee

**** ******** **.

Clearwater, FL ****5

727-***-****

Professional Summary

• Professional candidate with years of experience processing medical claims.

• Researched electronic provider dispute issues to determine the root cause of the dispute and re-process or adjust claim appropriately with established CMS regulatory guidelines.

• Communicated and participated in daily calls with the client coordinator, both verbally and in writing, to perform research, gather information related to the dispute, and resolve it appropriately.

• Reviewed medical claims submitted and made a determination to pay or deny based on members plan, providers policy, and procedure guidelines.

Education

• High School Diploma

Crestwood High School, Dearborn Heights, MI

• Schoolcraft College, Livonia, MI

• Bob Hogue School of Real Estate, St. Petersburg, FL Computer/Software Experience

• Health Suite, TriZetto Facets 2.96, 4.11, 4.21, 4.9, 5.01, Networx (Citrix Based Applications), eviCore authorization and referral system, WGS, Amisys, QNXT, Facets/Erisco, RIMS, GPOO, EZ Cap, ASA, CICS, Diamond, IDX, Quest, Gems, ASA

• Rumba and proprietary systems. Applications using iFacets within Notes7Desktop, Lotus Notes 8.5, MRU Data Base, HIPPA Gateway, Excellus Desktop, Repository, SIR 2005, Facet PRD 501, BLUE2 Inter-Plan Messaging System (Host mailbox), TOPPS

• Medical Records Requests on Saturn, Fingertips Intranet Claims Library, 10-key by touch, XP, Vista, Windows 7, 10, Outlook, Advanced Excel, Advanced Word, QuickBooks Premier 2018, Bookkeeping Specialist. Additional Specialized Experience

• Knowledge of medical terminology: ICD-9, ICD-10, HCPC Codes, 10-key by touch, CPT4, DRG, UB04, CMS1500, Medicare, Medicaid, Medicare Advantage and Managed Care, TPA, Indemnity, HMO, PPO, POS, EPO, Blue Card, Reinsurance-Excess Loss, Self-funded Care. Certificates

• Completed certificates from BizTech, Clearwater, FL 2018

• Advanced Excel & Word

• QuickBooks Certified User, Bookkeeping Specialist & Florida Notary bonded Professional Experience

Team Lead, Medical Claims Examiner - Remote Contractor Moda Health Plan, Portland, OR April 2022 – March 2024

• Processed ASO COB, Commercial COB group claims for medical provider network in Oregon and Alaska.

• Multiple application systems: Citrix Receiver Facets 22.3 Version (2023), Outlook email, ICM Research Manager, Excel SS, MS Teams, Availity Essentials, One Health Port, SharePoint Policies & Procedures.

• Contacting providers to send EOBs on COB claims.

• Processed complex COB Facility and Provider adjustments.

• Responsible for managing staff, including mentoring, training, motivating, facilitating production sheets. Medical Claims Examiner - Remote Contractor

Blue Cross & Blue Shield of Kansas City. MO February 2021 – July 2021

• Researched ASO, PPO, HMO, EPO for their Medical provider network. Multiple application systems: Citrix Receiver 4.9 Facets, Outlook email, EX Code Matrix OnBase, ECT Viewer & Apex.

• Determined if services were under COVID-19 related symptoms per diagnosis codes.

• Routing claims to Medical Management, New Directions or EviCore that requires review. Medical Claims Analyst - Remote Contractor

Presbyterian Healthcare Services, Albuquerque, NM October 2020 – December 2020

• Researched ASO PPO PHP Benefit Plans for Albuquerque Public Schools (APS) and New Mexico Public Schools Insurance Authority (NMPSIA) products.

• Multiple application systems: Citrix Receiver 4.9 & Facets, Outlook email, EX Code Matrix, OnBase, ECT Viewer & Apex. Their library for claims documentation and policies is DART.

• Coordinated benefits with Primary carrier, Medicare Part B and Dual PHP claims. Medical Claims Analyst - Remote Contractor

AuCourant Benefit Administrator, LLC, Kalispell, MT MMAI Medicare Plans November 2019 – February 2020

• Researched electronic provider dispute issues to determine the root cause of the dispute and reprocess or adjust claim appropriately with established CMS regulatory guidelines.

• Reviewed and evaluate contract terms, interpretation and compile necessary supporting documentation for the resolution of the provider’s disputed claim.

• Communicated and participated in daily calls with the client coordinator, both verbally and in writing, to perform research, gathered information related to the dispute, and resolve it appropriately. Team Lead, Provider Dispute Analyst, Auditor - Remote Contractor BCBS Texas, Richardson, TX

MMAI Medicare and Medicaid Managed Care Plans September 2018 – June 2019

• Responsible for managing staff, including mentoring training, motivating, and facilitating audits.

• Training team to research electronic provider dispute issues and determine the root cause of the dispute and route to the appropriate queue.

• Reviewed and evaluated contract terms, interpretation, and compile necessary supporting documentation for the resolution of a provider disputed claim.

• Communicated and participated in meetings with a variety of clients, both verbally and in writing, to perform research, gather information related to the dispute, and resolve it appropriately. Senior Medical Claims Examiner - Remote Contractor DST Systems, Birmingham, AL

Medicaid for WV, PA, and DE August 2016 – December 2017

• Reviewed medical claims submitted and made the determination to pay or deny based on members’ plan, provider’s policy, and procedure guidelines.

• Maintained 99% accuracy and production standards for the department of 17 claims per hour. Health Care Claims Specialist - Remote Contractor

Monroe Health Plan, Syracuse, NY

NY Medicaid Program for Rochester & Buffalo March 2015 – August 2016

• Reviewed medical claims submitted and made the determination to pay or deny based on members’ plan, provider’s policy, and procedure guidelines.

• Maintained 99% accuracy & production standards for the department. Senior Medical Claims Adjuster - Remote Contractor Excellus/Univera BCBS, Syracuse, NY

Medicare HMO/POS Managed Care November 2012 – March 2015

• IFacets Claims, Blue Card Host Adjustments.

• Review and process Facility, Professional, Lab, DME, Skilled Nursing claims.

• Maintain 99% quality and production standards for the department of 80 claims per day.

Contact this candidate