Jacqueline Dee Evans

**** ***** **** ******

Philadelphia, PA 19142

Phone: 215-***-****

Cell: 267-***-****

Email: aduhrb@r.postjobfree.com

OBJECTIVE: A quality assurance professional offering administrative accomplishments within the insurance industry. Seeking a career providing growth based on performance and accomplishments. EMPLOYMENT:

2010 - Present Casino Dealer, Harrahs Philadelphia

● Operating live table games

● Exchanging currency for cheques

● Greeting guest

● Explaining the rules of the table

● Making the guest experience enjoyable and fun

2005 – 2008 Provider Data Systems Information Administrator, Health America

● Enter new physician applications daily into the nominee status.

● Enter site visit requests for PCP’s and OBGYN’s through the Conrad PQI website.

● Complete notifications of provider changes and terminations in CPD and IDX systems.

● Complete review of returned mail and initiate the necessary system changes. 2001 - 2005 Quality Assurance, AHP Settlement Trust

● Audit legal claims to ensure claimant allegations for possible multi-tier benefits are processed correctly.

● Analyze and review claimant’s demographic information, medical records, and attorney correspondences.

● Communicate with superiors to resolve complex claim issues.

● Responsible for maintaining productivity and accuracy in accordance with the Trust standards. 1998 – 2001 Provider Appeal and Grievance Specialist, QualMed Plans for Health

● Researched the appeals and prepared cases for first level and second level reviews.

● Managed and coordinated follow-up on all review decisions.

● Produced all letters relating to Provider appeals and prepared reports for those appeals

● Communicated with the Provider regarding the status of their appeal.

● Maintained understanding of benefits, limitations, exclusions and Plan’s policies. 1992 - 1998 Provider Services Telephone Representative, QualMed Plans for Health

● Received and responded to provider calls.

● Communicated with clients regarding on changes in provider status.

● Requested for materials and orientations/in-services.

● Analyzed and responded with problem resolutions to inquiries regarding claims, capitation payments and fee schedules.

1990 – 1992 Coordination of Benefits Representative, QualMed Plans for Health

● Coordinated primary and secondary payments of claims.

● Investigated any claim that has been identified as possible COB.

● Contacted providers, medical groups, and members regarding plan policies and procedures.

● Handled monthly reports on COB activities and special reports as requested. 1985 - 1990 Claims Processor, Philadelphia Health Associates

● Processed medical claims received including eligibility claims.

● Reviewed medical records to verify approval of service for claims received.

● Contacted providers and members groups regarding claims issues and concerns.

● Researched and maintained all records of claims by using Lotus 1-2-3. COMPUTER SKILLS:

● Health Systems Implementation (HIS) Amisys

● Windows 2000 and XP Office Microsoft Word, Excel, PowerPoint

● Reilly – Dike – Dosher (RDD) I - Max

● Co-Med System Macess

EDUCATION:

West Philadelphia University City High School, Graduated 1982 – Diploma REFERENCES AVAILABLE UPON REQUEST

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