Claims Examiner Customer
Resume:
Felicia Renee Medrano
817-***-**** / *********@*****.***
Professional Profile
At this time, I am looking for a Full-time in the medical insurance industry. I am very loyal and a hard worker. I have over 28 years in medical insurance, from claims customer service to auditing. I have done it all. I am looking for a great company to continue my journey with.
Professional Experience
EBMS TPA, Billings Montana
Remote Examiner III (Part time, Then Fulltime) 2019-Present
Responsible for adjudication of healthcare claims utilizing employer and payer specific policies and procedures.
Run daily reports for management team.
Assign daily work to claims team
Assist with training of new hires.
Requested additional information, such as accident questionnaires, Police report, medical records.
Handle last minute deadlines, or special projects.
Request refunds when necessary
Mentor new hires
Handle escalated navigation que for hot issues.
Met or exceeded all performance goals.
Process daily incoming correspondence
System- Javalina
Coordination of benefits
US Health Group, Fort Worth Texas
Upgrade Case Manager, Medical Claims Analyst 2017-2021
Take incoming calls for existing members regarding increasing medical coverage due to a catastrophic event has occurred.
Create file for potential upgrades.
Completed necessary paperwork to start an upgrade case
Make follow up calls to members who have expressed interest in increasing coverage.
Works with other departments to ensure our member is taken care of
Assist with getting necessary paperwork needed for our claims department.
Notate our system with accurate information regarding calls.
Flexibility with work schedule to ensure phones were covered during business hours.
Assisted with training of new hires.
Maintained a compassionate and professional attitude for our members.
Assisted members with collection notices, balance bills and any other issue they may have with their medical accounts.
System-Legacy and AS400
Conduct investigation for Pre-existing conditions, accident investigations and subrogation, investigate due to plan exclusions.
Make outbound calls for requested or missing information such as medical records or documents needed from members.
Silverback TPA, Fort Worth Texas
Lead Claims Examiner 2014-/2017
Distribute daily mail to claims examiners.
Monitor daily reports to ensure claims are not going out of compliance.
Handle escalated calls from our claim’s customer service dept.
Train all new hires
Audit all new hires.
Answer questions from other departments regarding claim issues
Handle special projects from claim director and VP
Process medical claims
Call providers for missing data
Give weekly updates on claims inventory.
Cover for supervisor when absent.
System: QNXT and RIMS
Claims Auditor
●Analyze data to assess the accuracy of claims payments.
●Identify trends and anomalies within claims data and perform root cause analysis.
●Review plan documents, service agreements and provider contracts
●Communicate audit results in a structured report format within required timelines.
●Perform all job duties in accordance with HIPPA privacy and security rules.
●Requires strong judgment, critical thinking skills.
●Familiarity with medical terminology and ICD-10, CPT, HCPCS.
●Understanding of claims adjudication process
●Held weekly meetings on error trends.
●Worked with the financial department to stop payments/vouchers.
●Had to meet a daily deadline and approve or disapprove check vouchers by 1 P.M
Configuration
Configure medical, dental and vision benefits based on plan benefits.
Answer benefit questions from internal departments with a timely manner
Handle configuration issues, ensuring system has been corrected and run reports to see what claims have been affected.
Provide support to all other team members.
Research coding questions for other departments
Knowledge of CPT, ICD-9 coding and understanding claim bundling edits
Education
Boswell High School, Saginaw, Texas-GED
HealthMarkets Continuing Education Courses
Anti-Harassment
Code of Conduct and Ethics
Felony Convictions
Related Party Transactions
Relationship in the workplace
New Hire and Termination Procedures
Fraud Detection
Complaint Handling
HIPAA
Telemarketing Do Not Call
Security
OFAC Screening
Records Retention
Anonymous Hotline
Contact this candidate