Claim Analyst
Resume:
Professional Summary
Qualified, board-certified G.P & Nurse Practitioner with more than 7 years of experience in direct patient care. Highly motivated, dedicated and clinically competent with experience caring for patients from a range cultural background. I am committed to pursuing a role in which I can help people maintain their health and quality of life.
Skills
Proficient with MS Office (Word, PP, Excel)
Medical terminology expert
Proficient with Electronic Medical Records (EMR)
Medical prognosis expert
Medical Coding
Accomplished in primary and rehabilitative care
Clinical benchmarking
Records management professional
Fluent in French & Arabic
Hospital inpatient and outpatient records
Work History
Claim Analyst 01/20 to present
Responsible for independent review and timely/accurate processing of claims in accordance with DHS and CMS Regulations and Claims Department Work Instructions.
Work pending Files and provide timely communication as directed by CCO Leadership. Follow up on pending claims and adjustments accordingly to Department Service Level Agreements and regulatory requirements.
Interact with internal customers and other UCare Departments to obtain needed information to process claims and to provide detailed claim information for resolution.
Adjustment Specialist 07/2018 to 12/19
Research, analyze and resolve claim adjustment request for all UCare Product submitted for payment timely.
Provide timely communication on claim adjustment requests.
Process Adjustment based on Policies and Procedures, Coordination of benefits, applying appropriate plan provisions, CMS Regulations and DHS guidelines for payment determination.
Follow up on pending adjustments accordingly to Department Service Level Agreements.
Identify trends and/or issues, process improvement recommendations and communicate with claim adjustments Leadership.
UCare – Minneapolis, MN 03/2018 to 06/2018
Claim Examiner
Research, resolve, examine and process paper and/or electronic claims submitted for payment.
Interact with internal customers to obtain needed information for claim processing.
Process claims reviewing Policies and Procedures, Coordination of Benefits, and applying appropriate plan provisions, CMS Regulations and DHS guidelines for payment determination.
Ensure accurate and timely processing of claims in accordance with DHS and CMS Regulations and Claims Department Work Instructions.
Maintain department production and quality standards.
Work pending file as directed by Claims Leadership. Follow up on pending claims according to Department Service Level Agreements.
Interaction with internal customers to obtain needed information for claim processing
BlueCross BlueShield of Minnesota – Eagan, MN 07/2017 to 01/2018
Enrollment and Billing Representative Associate
Performed membership and billing activities for clients and /or members.
Verified enrollment status, record change requests, addressed enrollment questions and concerns and provided promptly and accurate responses to written inquiries.
Communicated effectively with internal contacts to resolve discrepancies in membership and billing information.
Managed multiple production-oriented tasks and responsibilities.
Involved in team activities to identify problems and improve work processes and systems as well as claim auditing.
Prime Therapeutics- Edina, MN 1/2016 to 06/2017
Clinical Review Assistant
Managed approval records (e.g., prior authorization overrides) at the drug-specific level.
Ensured the appropriate claim adjudication through health plan including Commercial and Government programs (Medicare and Medicaid).
Accountable for entering, reviewing, and documenting requests on claims processing system and the internal Request Tracking Databases
In charge of reporting of data activities to the company’s Clinical Research Network.
Demonstrated proper use of documentation of resources, training materials, and various systems.
Accountable for providing all relevant clinical information for prior authorization forms for Pharmacy Clinical Review.
Clinique Saint Dominique – France 01/2012 to 03/2013
Assistant Geriatric Practitioner
Served as Geriatric Practitioner and Primary Care Physician in various General Medicine and Multi -Specialty settings. Orchestrated Tasks such as:
Appropriately diagnosed and treated a variety of diseases and injuries in a general practice setting.
Ordered and executed diagnostic testing and analyzed diagnostic images to further investigate patient conditions.
Administered and prescribed appropriate courses of treatment, including pharmaceutical therapies.
Monitored patients' condition and progress and re-evaluated treatments as necessary.
Evaluated Patients physical and mental health and referred patients to specialist where appropriate.
Managed, directed and coordinated activities of nurses, nurse assistants and other medical staff
EHPAD La Palmerai – France 02/2011 to 01/2012
Geriatric Head Nurse
In charge of gathering patient's medical history to ensure that each individual receives the best care possible.
Prepared and administered medications
Daily reporting to Medical Director on patient specific activities and treatments performed.
Medical coordinator between Nurses and Physicians.
Insured clear and precise instructions to practical Nurses and assistant Nurses as necessary.
Headed a clinical team to deliver health care services that promoted optimal patient health.
Prepared blood, urine, stool and sputum lab specimens for diagnostic evaluation.
Performed monthly inventory and maintained medical supply counts.
fully developed departmental goals, objectives, standards of performance, policies and procedure.
EHPAD Bleu Soleil-Nice – France 02/2008 to 02/2011
Geriatric Staff Nurse
Managed team of medical support personnel.
Completed appropriate claims paperwork, documentation and system entry.
Assisted in the maintenance of medical charts and/or Electronic Medical Records (EMR)
Demonstrated ability to lead and motivate outstanding healthcare teams.
Questioned patients about physical and emotional health, lifestyles and diets to determine potential causes of pain.
Maintained regular communication with physicians, nurses, insurance companies and managed care organizations.
Military Hospital – Tunisia 04/2006 to 06/2007
General Practitioner (Medical Intern)
Cared for patients with Acute and Chronic Pain.
Treated 10-13 patients per day
Obtained and analyzed laboratory results.
Triaged patient calls, questions and concerns.
Monitored patients' condition and progress and re-evaluated treatments as necessary.
Continuously maintained proper safety and promoted precautionary measures to avoid the spread of disease and infection.
Confidently managed the hospital operation of nursing services and patient care, including quality assurance and patient care.
CHU Charles Nicoles – Tunisia 02/2005 to 03/2006
General Practitioner (Medical Intern)
Performed physical examinations of patients and planed follow-up and preventive treatment.
Maintained and coordinated the relationships with the County Sanitary Department and the Public Hospital.
Scheduled appointments, registered patients and distributed sample pharmaceuticals as prescribed.
Completed appropriate claims paperwork, chart review and documentation.
Meticulously identified and rectified inconsistencies, deficiencies and discrepancies in medical documentation.
Education
Institute - Formation en Soins Infirmiers des Alpes-Maritimes – France 2010
Bachelor Degree: Family Nurse Practitioner
2008
University of Nice - Sophia-Antipolis- Faculté de Médecine de Nice – France
Associate of Applied Science: Medical Coordinator of Elder
2007
Faculty of Medicine of Sousse - Tunisia
MD (Bachelor of Medicine): General Practitioner/Family Practice
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