Claims Specialist Benefits Administrator

KIRSTIN L. MCMILLAN

Phoenix, AZ ***** • 928-***-**** • adwevl@r.postjobfree.com

MANAGER DRIVEN BY PASSION

Driven by a passion to help members understand and utilize their coverage to the fullest, while adhering to the latest Medicare, Medicaid, commercial and government compliance regulations. With over 10 years of dedication my experience is extensive, always eager to learn more. WORK EXPERIENCE

Oncology Analytics, Remote, AZ Oct 2020 - April 2022 Coverage Review Department Lead

● Improved overall department productivity by 20% after restructuring.

● Adhered to strict protocols according to client contract turnaround times (TAT)

● Collaborated with leadership to support business objectives and regulatory compliance.

● Evaluated medical guidelines and benefit coverage to determine service appropriateness. McKesson Specialty Health, Scottsdale, AZ Jan 2018 - Sep 2020 Senior Case Manager

● Ensured compliance with local, state, and federal insurance and Medicare/Medicaid regulations.

● Edited and resubmitted denied claims to achieve financial targets and reduce outstanding debt.

● Coordinated payer issues with the contracting department.

● Functioned as insurance coverage SME for all internal and external questions and inquiries. United Healthcare Group, Telecommute, AZ Nov 2015 - March 2017 Medical Claims Coordinator

● Created POC mailing requests for members and providers.

● Administered benefits claim processing, claims principles, prior authorization determinations within HIPAA regulations.

● Coordinated large daily medical claim submissions.

● Reviewed patient notes to submit requests and verify accuracy. Express Scripts, Remote, AZ April 2010 - Oct 2015

Prior Authorization, Department Lead

● Established a top-ranking team with a 99%+ accuracy rate.

● Organized team schedules, department projects, and quality assurance initiatives.

● Facilitate resolution of drug coverage issues and pro-actively address, research and resolve issues while maintaining accurate and complete documentation of all inquiries for continuous improvement.

● Pharmacy benefit reviews and coverage determinations EDUCATION

South University, Savannah, GA 2013

Associates Medical Science

Scottsdale Culinary Institute Le Cordon Bleu, Scottsdale, AZ 2010 Bachelors Culinary Arts & Hospitality Management

SKILLS

Case Director • Claims Director • Pharmacy Benefits Administrator • Executive Claims Specialist Provider Reimbursement • Regulatory Compliance • Document Verification • Insurance Coverage

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