Claims Processor Analyst
Resume:
Amber Ready
Tampa, FL ****3
******************@*****.***
Employment History
Current NTT DATA Position
HC & Insurance Ops Sr. Rep, (remote) NTT DATA, Formerly Dell [Wellcare Contract]
July 2015 to present
Responsibilities include:
●Medicaid (Florida) Plan; audits, appeals, correspondence, hold files
●Coordinate Benefits as needed
●Manually adjust as needed
●Xcelys processing system
Previous Dell Position
HC & Insurance Ops Associate, (remote) Dell [United Healthcare Contract]
April 2015 to July 2015
Responsibilities included:
●Examine Medicaid claims and calculate reimbursement based locale and CPT
●Reprocess/adjust per SOP applicable
●Audit assigned special projects as needed for United Health Care (client)
●Diamond 950 processing system /Xcelys
●Medical Transcription
Most Recent Prior Position
Dialysis Claims Analyst, Innovative Medial Risk Management, in St. Petersburg, FL
Oct 2014-April 2015
Responsibilities included:
●Medical and Dialysis claims processor
●Repriced and analyzed claims
Most Recent Prior Position
Hired as -Claims Processor/Auditor, promoted [10/2012] to Compliance and Grievance Analyst
Co-ordinated Benefits Plans, in Clearwater, FL.
June 2012-September 2014
Responsibilities included:
●As Processor- Repriced short term medical claims using applicable network (PHCS, Beechstreet), ensuring proper payment per contracted rates and line of business (Travel, STM, PFFS)
●Process medical claims in Quicklink, Facets, Epic and TRIZETTO environments
●Wide experience in configuration data management and medical claim processing
●Profound knowledge of codes applicable in CPT, HCPC, Revenue and ICD-9/10 systems.
●As Analyst- Thoroughly research and resolve root causes of complaints, appeals and grievances, prepare review methods, analytical techniques and compliance routines
●Modify the organizational policies or the contractual terms to ensure adherence with the industry standards and the ever changing law
●Audit claims per plan documents, as well as processing procedures
●Responsible for researching and responding to Complex Subrogation cases and DOI appeals and complaints
●Inventoried, tracked and trended all incoming appeals and grievances
●Sent complaint reports to carriers according to the Third Party Agreements
●Facilitate responses and case preparation for litigation, reprocess per Carrier direction
●Take suitable action in response to BBB, DOI, or other regulatory agency involvement
Other Positions:
Team Lead for Resolution (Escalations) Department, Universal Healthcare,
October 2010-June 2012
I was initially hired as a Claim processor. This included a quota of claims (100 daily) in Facets and proper documentation, within Medicare and Medicaid timeframes. I was then promoted to Team Lead for Claim Resolution Team. I then managed a team of Resolution Specialists who resolved complaints, escalated issues, difficult and special cases. This included auditing, reprocessing and taking appropriate action on claims as well as responding to CTMS, grievances and appeals.
~COBRA/ARRA Compliance Representative, Kelly Services/Ceridian, March 2009- October 2010
~Sales and Training, St. Petersburg Times, Oct 2008-March 2009
~ Teacher (consumer math/social skills), Oak Park Oct 2007-Oct 2008
~ Diversion and Education Representative, CCS Medical Feb 2006-Oct 2007
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