Colette Martin

Claims Specialist

Contact

626-***-****

Mobile

addnfj@r.postjobfree.com

Objective

Maintain productivity and quality standards as defined by Management. Communicate with other departments to resolve provider claims related issues. Contact providers either telephonically or in writing for additional information to resolve or clarify submitted claims issues

Education

California State University of Los Angeles

Los Angeles, CA

Graduated: 12/2010 B.S.W. B.A. Under Health Science Department

Experience

January 2020 - March 2020

PDR Claims Specialist • The Judge Group Agilon Health Care • Company/Agency:

Research and evaluate contract terms/interpretation and complies necessary supporting documentation for the resolution of provider disputed claims under the PDR Department Provider Disputes and Resolution department. Respond to incoming provider disputes accurately, timely, and in accordance with all est. regulatory guidelines. Process /adjudicate and notate the claims accordingly within the claim systems. Update tracking system of provider disputes and appeals. Properly distinguish between a provider dispute and a provider appeal and generates and/or escalates a provider appeal for payment. Provide Interest and Penalty updates to previously paid claims per CMS Audit of claims within the VANTAGE and LAMC accounts of MEDICARE and MEDICAL Health Plans.

June 2019 - September 2019

Enrollment Specialist • ARTECH AGENCY CONTRACT •

Company/Agency:

Major Responsibilities/Essential Functions

Worked with Practitioners and Facilities within government programs. Assist the Provider and Facility Enrollment Coordinator and Management with Unit production.

Enroll and terminate providers, practitioners and facilities with CMS and other government programs by completing 855 series forms, gather credentials and associated documentation required for enrollment and process enrollment forms. Track status of in process enrollment forms until final approval received.

File provider/practitioner/facility ID numbers once assigned by governing agencies and perform system updates as appropriate. Maintain forms that meet the standards of state and federal legislation and accrediting body standards. Partner with MAPMG and Health Plan Human Resources and Practitioner and Provider Quality Assurance to research and process internal or external requests regarding provider/practitioner licensure, credentials, and assigned ID numbers. Follow up on claim denials related to enrollment issues.

October 2018 - December 2018

Claims Specialist Recovery • Cal Optima • HCT-Company/Agency

Recoup and retrieve claims payments made in overpayments to accounts and erroneous service codes. Hospital and professional services payments made to provider accounts. Benefits and eligibility verification as well as CPT/ICD 9 and 10 checks to provider accounts made in error recovery.

Followed established policies and procedures and use available resources such as provider contracts, Medicare and/or Medicaid guidelines and Member Evidence of Coverage (EOC) to process, and adjust routine assigned claims in an accurate and timely manner.

Performed payment reviews and adjustments due to retroactive effective date of contracts and/or fee schedule changes.

Participated in system testing and communicates newly identified and potential issues to the Claims Supervisor and/or Manager.

Attended and actively participated in daily, weekly, and monthly departmental meetings, training and coaching sessions.

Resolved claims payment issues as presented through Provider Dispute Resolution (PDR) process and/or provider calls.

Maintained productivity and quality standards as defined by Management.

Communicates with other departments to resolve provider claims related issues.

Contacts providers either telephonically or in writing for additional information to resolve or clarify submitted claims issues.

Handled misdirected claims inquiries phones and mail.

February 2017 - June 2017

CARE ASSOCIATE -CUSTOMER SERVICE -AUTHORIZATIONS MEDICAL

Cigna Healthcare Permanent

Work in the Medical Precertification department as a Care Associate to enter National and California HMO authorizations for providers who are performing medical services for members of Cigna Healthcare. Verify benefits, HIPAA standards, Check CPT 10 codes as well as Case Management standards to ensure the credible creation for precertification’s of its members.

Customer service with health providers and members of health documents information. verify HIPPA or pre-certs /authorization of health records. Check for medical necessity of medical codes for ER or Hospitalization or outpatient services.

April 2016 - February 2017

Beacon Health Options Permanent

CLINICAL CARE ASSOCIATE

LA Care Mental/Behavioral Health Entity

Work to network members within LA CARE Health Plan to Behavioral Health Services. Customer Service and Clerical duties for setting up Vendor Appointments for members who accept health care services for behavioral/mental health issues. Enter DMH authorization for clients of LA Care. Edit and document reports; Customer Service call members and enter provider appointments. Call DMH and providers of behavioral health appointments. Verify transportation of members to appointments.

Edit data o documented services provided. Discuss Housing and Mental Health Issues with members in need of Social and Physical Services to the low-income population. Connection to social services and access information regarding housing, food and other daily living for survival. Training skills of Education- where to connect for services.

Perform outbound calls to providers to obtain additional information needed to certify cases. Access automated case system to open / document cases. Perform certification using scripted guidelines.

May 2015 - October 2015

LA CARE, HCL, OSLO Agency- Company/Agency

CONSULTANT CLAIMS EXAMINER

MAIN DUTIES AND RESPONSIBILITIES (Essential Functions of the Position):

Functions as a Tester and Consultant for liaison between Production Technology, Account Management teams an Medical of Systems and analysis- gathering, defining and understanding client’s needs in regards to transition of ICD9 /ICD10 codes relationship with in the [program of QNXT] TriZetto systems with regards to the adjudication and processing of medical claims for various lines of business.

Process CAL Works Claims for MEDICAL and Medicare Claims for LA Care Member Claims. As well as verify Benefits for members under LA Care services of medical providers according to contract information and terms of agreement to covered benefits from underwriter (s) Evidence of Coverage.

Elicits, analyzes, validates, specifies, verifies and manages the requirements of the client in regard to HMO, MEDICAL and MEDICARE accounts for Medical Groups and Lines of Business within Health Organizational system.

Transforms the business requirements and solution into Project Charter, Client Requirements Document (CRD) Conceptual Design Document/Functional Specifications for CCA. And rom MHC to QNYXT.

08/2013 - 05/2015

Molina Healthcare, Long Beach, CA- PERMANENT

CLAIMS EXAMINER III HOSPITAL CLAIMS

Manually process all hospital claims of New Mexico for adjudication of all HMO; Medicaid claims. Process Indian Health and Dental claims.

08/2013-04/2014

Kaiser-ARTECH Agency - Company/Agency

BUSINESS ANALYST-Claims Examiner

Worked in the Compliance/Sales Case Installation department to update CMS Kaiser Benefit manuals distribution for Small and Large business groups within the Kaiser enrollee benefit department.

Worked on the SBC Team for completion of update of the affordable care act ramifications for all of Kaiser's Lines of Business using SAP; Share Point to Update Information for Sales/Underwriting Teams.

Worked on Excel Spreadsheets for mapping all the contract information. Worked on Share Point; CARS, Spreadsheet for Excel and PDF updates; Edit contract information necessary for changes to underwriting /sales information for representation of contract updates Produced over 50 documents on a monthly basis of new edited brochures for compliance updates required by the State of California and the Affordable Care Act deadlines.

**Gaps-Employment Period = 2010 to 2013- Took Homecare of Elderly Relative and Attended College-Social Work CSULA**

08/2004 to 01/2010

Anthem WellPoint Blue Cross -PERMANENT

Claims Adjudicator

Worked on CalPERS unit to process PPO and POS as well as Medicare, OIC, COB claims for vendors and benefit members within the BlueCross health insurance plans. Three tiers system of Medicare; Point of Service and Preferred Provider Claims Process. Processed and adjusted of claims paid in addition to rebills or reconsideration for appeals or missed payments. Verify member benefits and policy and procedures of various providers contracted and non-contracted accounts. Processed over 350 claims on a daily basis and achieved 100% quality.

Key Skills

Communication

TriZetto, Cognizant, QNXT, CCA-Utilization Facets; Centrix ; Cotivity Editing ; EZ-Cap; Diamond and Epic; Revenue Cycle System Review Application; WGS; IDEX; People Soft; MCH.3MCore –DRG/ Encoder Pro, People soft, EZ-CAP, EPIC, QNXT versions 4-5, AS400, SAP; WGS, IDEX, Kaiser systems-Same time, IM81-Tapestry, Foundations, Faucets, Diamond; MHC (Managed Health Care Systems), Cars and Share Point.

Leadership

Worked in the Compliance/Sales Case Installation department to update CMS Kaiser Benefit manuals distribution for Small and Large business groups within the Kaiser enrollee benefit department.

Worked on the SBC Team for completion of update of the affordable care act ramifications for all of Kaiser's Lines of Business using SAP; Share Point to Update Information for Sales/Underwriting Teams. Worked in Appeals and Grievances unit as Claims Adjuster/Examiner to process health insurance claims for various insurance and HMO, TPA, IPA's.

Canalization of claim accounts of vendors and providers of erroneous or reconsideration of accounts. Electronic data imaging view of claims regarding HCFA 1500 and UB92/94 to ensure proper claim handling and processing of claims were allocated to correct accounts.

Researched problem claims for benefit level, third party liability, overpayments, and inappropriate coding.

Earned a reputation as a valuable and cooperative coworker by: being fair, honest, and willing to help others when needed; effectively resolving conflicts at appropriate times; and assisting new managers and other staff to become familiar with policy and operations.

Developed ideas for duplicate bills to ensure system and examiner errors were caught to ensure overpayments and underpayments.

References

[Available upon request.]

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