Data Entry Claims Examiner

PAULETTE WHITE

San Antonio, TX

********@***.*** 210-***-****

HIGHLY FOCUSED & DETAIL-ORIENTED ACCOUNT MANAGER

Exceptional Record of Provider Service, Serving as Single Point of Contact for Specialists, Primary Care Physician, Multi-Specialty Groups, & Hospital Systems Aspire to achieve perfection through self-motivation and excellent analytical skills. Accomplish quality results through team leadership, interpersonal skills, and process management. Assist in credentialing and re-credentialing process to ensure provider’s applications are correct and expedited. Build and maintain professional relationships with the providers to ensure provider satisfaction. Research and resolve disputes and billing discrepancies. Manage multiple simultaneous projects with high efficiency and accuracy. Liaise between providers and company regarding contract and data compliance.

Employee Relations Hiring and Retention HCPCS ICD and CPT Coding HIPAA Guidelines PROFESSIONAL EXPERIENCE

HEALTH ADVOCATE-San Antonio, TX 2019-PRESENT

Supervisor

Supervising workflow of all incoming calls and cases for area of responsibility (e.g., triage, benefits, claims, appeals, etc.) which includes developing and implementing policies and procedures, training staff to perform specific functions and managing employee performance. Monitor calls and audit case files daily to ensure the proper target resolution is identified and that, if possible, the case is closed at or near the target resolution. Review operational reports and analyze staffs needed and make the necessary adjustments and or plans to improve results, which includes, adherence to hours worked, time spent resolving cases, and case documentation. Analyze data reports to make timely decisions and effectively implement plans. SUPERIOR HEALTH PLAN, San Antonio, TX 2014 – 2019

Account Manager

Conducted initial provider orientations, providing ongoing educational outreach.

Educated providers, ensuring accurate transfer of information regarding policies and procedures related to referrals, claims submission, credentialing documentation, website education, Electronic Health Records, Health Information Exchange, and Electronic Data Interface.

Enhanced account relationships by investigating, documenting, and resolving provider matters and effectively handling and responding to account changes and correspondence.

Created communicated milestone documents and dashboards, communicating success or improvement metrics.

Liaised between provider and health plan, ensuring coordinated effort in improving financial and quality performance.

Provided information and status updates for providers regarding incentive agreements, accessing patient profiles cost of care information, monitoring emergency room visits, and receiving reports on total cost of care.

Conducted site visits when required, measuring Provider office physical accessibility and adequacy of waiting and examination room space and medical / treatment record keeping.

BENEFIT MANAGEMENT ADMINISTRATORS, San Antonio, TX 2014 Claims Operations Manager

Supervised adjudication of claims, supporting provider satisfaction, retention, and growth.

Managed coordination of third-party resources, coordinating benefits and payment recoupment.

Ensured quality standard was met by developing, training, evaluating, and coaching staff to provide cost effective claim review / processing and claim service.

Managed performance and resource management of examining staff handling new claim inventory, mail correspondence, appeals, and special handling.

Assisted examiners with increasing performance and processing of claims by overseeing all aspects of aging inventories and managing personnel- related matters, including performance planning and appraisal, salary administration, hiring, training, and progressive disciplinary actions in accordance with company policy, procedures, and job aid. FCE BENEFITS, San Antonio, TX 2013 – 2014

Claims Auditor

Investigated Medicare claims data and medical records, identifying payment errors.

Analyzed and validated audit findings according to CMS regulations and guidelines.

Communicated with management on audit findings, assisting with error validation process. WELL-MED MEDICAL MANAGEMENT, San Antonio, TX 2008 – 2013 Claims Examiner II / Supervisor

Maintained current knowledge of Secure Horizon, Medicare benefits, provider network development, and contract issues, as well as industry standards for claims processing issues.

Supervised 25 claims employees, monitoring aging of claims of team members and taking corrective action when not in compliance. Interviewed, trained, and supervised new claims examiners and data entry personnel.

Read and interpreted contracts, processing medical claims and training on how to interpret contracts for processing high dollar hospital claims

(DRG).

Assisted with contracts, interpreting benefits and ensuring payment were configured correctly on IKA system.

Identified staff vacancies, recruiting to fill positions and conducting orientations that fostered positive attitudes toward organizational objectives. COVENTRY HEALTHCARE, San Antonio, TX 1997 – 2007

Customer Service Supervisor / Representative

Supervised and trained and assisted staff of 20 employees, maintaining records and preparing weekly progress reports.

Performed external recruitment and reviewed applications / resumes, creating training workflow process for new hires.

Designed and implemented streamlined process for Customer Service Representatives, increasing overall efficiency and resolving all escalated customer service calls.

Served as point of contact for open enrollment and job fairs, setting up booths and interviewing potential employees.

Maintained productivity reports and conducted QA on staff responsibilities, ensuring team workflow, production logs, and system functions were in check.

ADDITIONAL EXPERIENCE

PRUDENTIAL INSURANCE, San Antonio, TX

Supervisor / Manager

EDUCATION

Master of Health Administration (MHA), Webster University, San Antonio, TX, 2016 Master of Science / Human Resource Management (MS / HRM), Webster University, San Antonio, TX, 2010 Bachelor of Business Administration (BBA), Wayland Baptist, San Antonio, TX, 2006 PROFESSIONAL SKILLS

Microsoft: Word, PowerPoint, Excel, and Outlook

Coursework: Dean Vaughn Medical Terminology; Anatomy and Physiology

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