Claims Supervisor, Customer Service, all included in my resume
Resume:
Mary E. Jones (M.J.)
Colorado Springs, CO 80922
***********@*****.***
Overview
Seeking a position in the claims/customer service field. Utilizing my 10+ years in supervising medical insurance relulations, policies and procedures. To provide effective oversight of the daily operations within a department. To ensure accurate and timely resolutions of issues while ensuring compliance with applicable laws and regulations.
Skills
•Analytical thinking.
•Implementing efficient protocols and structure.
•Follow through while insuring attention to detail.
•Organizational and prioritization skills.
•Proficient in Microsoft applications, Typing 70 w.p.m. and 10-key.
•Individual and team building/development.
•Proficient in ICD9, ICD10 and HIPPA guidelines.
Employment
Sunnyhill, Inc.
St. Louis, MO
January 2019 - November 2021
Home Manager, Providing services, programs, and opportunities for 3 adults with developmental disabilities. Empowering them to become productive citizens and achieve their goals in a residential setting.
•Managed a team giving 365 days/24hr on-call support to 3 adults with medical and developmental disablities, living in a home setting.
•Ensure that staff working at the site provide care and guidance to the people we supported in accordance with all legal regulations, policies, procedures, and training.
•Documented, monitored and managed the residents finances with Medicare, Medicaid and State Trusts.
•Communicate consistently and positively with guardians, service coordinators, and other service providers. Being proficient and knowledgable in the Human Services field with the disabled.
•Taking and scheduling of residents to medical/dental/eye appointments. Providing documentation of appointments to State and service coordinators.
•Maintain staff schedules, ensuring appropriate staffing in accordance with contractual staffing pattern and budgets. Coordinate all aspects of filing direct care shifts as needed, without utilizing overtime hours.
•Certified in medication management and emergency life saving protocols. Managing the process and recordings of prescription medications being passed to residents.
•Train, supervise, and document the supervision of all staff at assigned work site. Completing 90-day evaluations and annual appraisals for all staff.
•Ensure household is operating efficiently and effectively. Created weekly menus, lists of groceries and household supply purchases. Kept inventory of individuals personal supplies and balanced it with their monthly budget and finances.
MAGELLAN HEALTH SERVICES
St. Louis, MO
May 2001 - June 2018
Diversified Specialty Healthcare Management Organization
Claims Supervisor (November 2006 - June 2018)
•Managed a team of 12 associates, including performance management and coaching for career development.
•Implemented procedures and documented all account specific nuances.
•Provided the staff with detailed training of all account, claims systems (CAPS) and standard documentation.
•Recruit, attract, motivate and manage a high caliber of lead claims processors, claims resolution specialists and processing specialists.
•Responsible for daily oversight and management of staffing resources in response to fluctuating claim receipts/inventory to assure all customer, state and federal performance requirements are achieved. Analyze multiple data source reports to ensure performance remained at peak levels.
•Responsible for the management of claims, timeliness and personnel.
•Managed claims processing for multiple business lines; Commercial, Employer Solution, Medicare and Medicaid businesses.
•Assisted and was a SME in several group implementations.
Claims Team Lead (March 2003 - November 2006)
•Assisted in identifying trends and ongoing training needs of the team. Led weekly training sessions with the team and individuals in a monthly one on one basis.
•Answered all claims related quesions from a team of 16 associates.
•Trended audit errors to assist the Supervisor in minimizing risk, while increasing accuracy.
•Handled all team member's audit errors for the month. Reviewed and managed all audit rebuttals for the individual processor and the account. Managing and recording all follow thru of these rebuttals for possible adjustments.
Claims Resolution Specialist (November 2002 - March 2003)
•Reviewed claims sent by customer service for possible adjustments of incorrect claim payments/denials, based on procedures and benefits of the plan.
•Identified systematic issues that caused multiple claims to have to be adjusted for the same error. Elevating appropriately to different departments to fix the system error.
•Perform detail member reviews of overall claims payment and accuracy of denials. If errors were identified adjustments were made of effected claims.
•Maintained an overall and financial accuracy rating of 99% as well as a production of 100% and above daily.
•Backup for Customer Service taking calls from Members, Providers and Account Management. Providing front to end resolution of any claims paid/denied incorrectly.
Claims Specialist II (May 2001 - November 2002)
•Processed claims for all levels of care and multiple lines of business for multiple accounts.
•Prioritizing claims processing by the timeliness of the various accounts.
•Maintained an overall and financial accuracy rating of 99% as well as a production of 100% and above daily.
Education
Graduate of St. Francis Borgia Regional High School, Washington, MO - 1986
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