Medical Claims Analyst

NICOLE C. HOLLIDAY

*** * ********** ******, ********** MI 48838, 616-***-****, *******@*****.***

OBJECTIVE

To secure a remote medical claims analyst position with a potential for career advancement. HIGHLIGHTS OF QUALIFICATION

· 12 + experience providing outstanding administrative and personal support.

· 10 + years’ experience with ICD 9 and CPT billing codes

· Analytical and interpretation skills including departmental, utilization, financial and operations data.

· A motivated self – starter, able to quickly grasp issues and attend to details while maintaining a view of the big picture.

· Expert in managing multiple projects and achieving on-time completion.

· Creative, resourceful and flexible, able to adapt to changing priorities and maintain a positive attitude and strong work ethic.

· A clear and logical communicator, able to establish rapport with clients and colleagues, and motivate individuals to achieve organizational objectives.

EXPERIENCE

MEDICAL CLAIM ANALYST 2015- CURRENT

ASR HEALTH BENEFITS

· Adjudicate medical, vision, and dental claims with 99 % accuracy.

· Determining third party liability on accidental claims and issuing correspondence to members to ensure completion of proper paperwork is documented.

· Document and research incoming correspondences, pricing appeal, member appeals and authorizations are completed in a timely manner.

· Assist members with claim questions and billing statements.

· Assisting provider’s on vision, dental and medical claim issues and statuses.

· Look up policy/benefit information and accurately relay the information to the providers/members.

· Answering a multi-line phone system and transferring calls to the appropriate department.

· Assisting in audit reports and updating provider information.

· Utilize the ASR health benefits website and Qiclink to look up confidential patient information and provider claim submissions.

· Process approximately 150 to 300 pharmacy invoices for the finance department weekly.

· Work with other departments and analysts to effectively handle provider/member concerns or issues. CONSUMER AND FAMILY LIAISON 2008 – 2014

APS HEALTHCARE, INC.

· Direct contact with the Board of Review to track requested hearings, preparing hearing documents and scheduling the hearings in accordance with West Virginia’s Medicaid Fair Hearings guidelines.

· Tracks, schedules and attends service negotiation and hearings related to denial of services or eligibility; communicate disposition of the negotiations and hearings to members, the department and other stakeholders

· Responds, processes and tracks all member/family complaints.

· Scheduling and preparing for quarterly meetings for the Quality Improvement Council.

· Attend and present at the Quarterly Provider Meetings to assist with education on policy and related issues based on systemic trends, public opinion and research.

· Assisting individuals and the family members of individuals diagnosed with Intellectual and Developmental Disabilities in the eligibility process for the I/DD Waiver Program.

· Providing training and technical assistance to various agencies and families who interface with the Title XIX Waiver Program.

· Data entry, oversight and management of online records through the Care Connection program for 4,532 individuals on the WV I/DD Waiver Program statewide.

· Responsible for direct Agency Interface with Providers who provide services to individuals on the Title XIX Waiver Program along with assisting with the eligibility process.

· Entering prior authorization claims into the Citrix Molina system to ensure timely and proper payment for services delivered.

· Responsible for monthly data analysis for reports that were reported to CMS as well as researching and troubleshooting processes related to data analysis and management.

· Researching disallowance reports and assisting with claim denials and NCCI and MUE edits.

· Responsible for management and data entry of Individual Diagnosis and ICD 9 Code Interface to ensure proper review of eligibility documentation.

· Responsible for assisting in development of process revision following the release of the new WV I/DD waiver Program Manual effective October 1, 2011. FRONT OFFICE ASSISTANT 2005-2008

MEDEXPRESS URGENT CARE

· Responsible for direct customer service and assistance with the registration process for patients coming in with illness and injuries.

· Direct data entry of patient demographics and verification of insurance information thru the Navinet software and Molina Medicaid system.

· Process payments, post balances and complete phone sheets.

· Discharge patients, assist office and clinical staff and close office at end of night.

· Handling all the oversight and processing of Workers Compensation claims by verification of diagnosis and ensuring the proper coding required for claim submission and making referrals to specialists.

· Assisting the Pharmacy Program in payment collection and data entry of prescription information thru the software system.

· Answering a multi-line phone system and transferring calls to the appropriate department within the clinic

Proof Operator (Temporary Position) 2005-2006

Express Personnel/BB&T

· MICR encode deposits and debits. Check for teller or personal errors and correct them with departmental proof slips

· Ability to work under pressure in a fast paced environment as well as to meet company deadline

· 1900 keystrokes, with a 90% accuracy.

Estimator (Temporary Position) 2005- 2006

Express Personnel/Innova Electronics

· Set up spreadsheets daily, for quotes with Microsoft Excel for a variety of prestigious companies.

· Research stock and availability of products, and email out stock needed to numerous companies for quote.

· Input data received and compare and contrast prices for quote. Work directly with outside sales for questions or concerns that arise.

· Ability to multi task, and work on a deadline of about four days for each quote when received. Student Supervisor 2003-2006

Ferris State University

· Help place and supervise approximately 25 student workers daily, to designated areas around campus.

· Assisted with the making and adjusting of the schedules, administering paychecks, opening and closing the office.

· Ability to promote worker productivity, paying attention to detail for daily reports for school to work programs, great written and verbal communication.

· Answered and transferred calls for a multi line system, set up appointments.

· Data Entry, light filing, faxing, copying, and organizing confidential client information.

· Utilized computer programs like Word, Office and Excel Spreadsheets. 84 WPM

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