Payment Integrity Complex Claims

SUSAN CLOUTIER

Dudley, MA 774-***-**** ********@*****.*** linkedin.com/in/susan-cloutier

CLAIMS PAYMENT INTEGRITY AUDITOR

Highly accomplished, efficient, and extremely dedicated Claims Payment Integrity Auditor. Unique ability of accurately processing and accelerating claims very quickly which allows providers to get their claims paid on time. Proven track record of successfully completing hundreds of claims daily, meeting stringent deadlines, and consistently exceeding provider expectations. Skills and qualities include:

ICD-10 Coding

Refund Check Processing Management

Solid Processing Accuracy Record

QNXT Software

Managing Complex Claims

Performing & Managing Audits

PROFESSIONAL EXPERIENCE

FALLON HEALTH, Worcester, MA 2018 – 12/2022

Claims Payment Integrity Auditor

Achieved a 100% claims processing accuracy record for 12 consecutive months.

Exceeded provider expectations by consistently confirming payment resolution for identified claim overpayment recoveries in a timely, accurate, and efficient manner.

Processed complex claims and ensure correct payment of authorized claims following established protocols. Result: Fallon paid zero interests on outstanding claims

Ensured compliance with contract administration and service level requirements through claim reviews and client appeals.

Managed the negative/credit balance process for Fallon Health, FHLAC, and FHW which ensured funds were recouped timely and accurately.

Successfully managed the refund check process for the Claims Department as well as the Provider Audit, Hospital Bill Audit, DRG validation, implantable & high-cost pharmaceutical audit.

Responsible for claims impacted by code editing software.

ALLIED HEALTH MEDICAL MANAGEMENT, Leicester, MA 2015 – 2018

Medical Biller and Coder

Ensured payment resolution for identified claim overpayment recoveries in a timely, accurate, and efficient manner.

Processed complex claims and ensures correct payment of authorized claims following established protocols.

Ensured compliance with contract administration and service level requirements through claim reviews and client appeals.

Billing and coding for established providers, using ICD-10 coding requirements.

CERTIICATION & EDUCATION

Certification: Medical Office Certificate

Education: Business Marketing, Providence College. Hours completed: 60

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