Los Angeles Claims Analyst
Resume:
Colette Martin
Education
California State University of Los Angeles, Los Angeles, CA Dec 2010
Bachelor’s Degree Social Work
Skills
Documentation review
ICD-10
Medical billing
Dispute resolution
Analysis skills
Pharmacy software
QuickBooks
Managed care
CRM software
Information security
EDI
Google Suite
Microsoft Office
Customer service
Quality audits
Data analysis
ICD coding
SQL Tables Testing
Work experience
Rose International
April 2024 to June 2024
Claims Analyst/ Revenue Recycle
Rose International - Kaiser
Project to enter contract information for the provider- facility. Short project for the department.
Collect backlog information and update for the department of claims benefits.
October 2023 – November 2023
Claims Analyst /Revenue Recycle
E Team Sutter Health Care
Project to enter contract information for the provider- facility. Short project for the department.
Collect backlog information and update for the department of claims benefits.
Maxonic Staff Agency - Change Healthcare, TN Oct 2022 – Mar 2023
COB Claims Analyst
Coordination of Benefits Analysts are responsible for using established methods to investigate, verify, and record third party liability (TPL) coverage information on behalf of our Medicaid payer clients per Availity and Emdeon systems.
COB analysts research TPL coverage leads through various methods including phone calls, correspondence, and online portals.
COB Analysts maintain accurate TPL coverage to trigger appropriate cost-avoidance and recovery activities.
COB analysts also respond to client research requests and may be assigned other tasks as requested by management.
Update tracking system of provider disputes and appeals.
Properly distinguish between a provider dispute and a provider appeal and generate and/or escalate a provider appeal for payment.
COB analysts operate in a fast-paced, production environment and take ownership of their work product by understanding the value of timely, accurate TPL lead investigation. Responsibilities:
Ability to adapt to the significant and frequent changes of the healthcare market.
Ability- to- work within a team environment with a positive attitude.
Detail oriented with strong investigative skills.
Ability to think critically and analytically regarding trends and patterns in data.
Proficiency with time and workload management with the ability to multitask.
Able to efficiently make a medium volume of outbound calls to various insurance carriers.
Very strong verbal and written communication skills
Proficiency Microsoft Windows and Office products (esp. Word and Excel)
Overtime may be needed based on company specifications Worked to edit; update COB accounts for review of Medical and Medicaid verification of Insurance information for United Health Care for Pharmacy (Rx scripts and Transactions under Emdeon). Check for secondary insurance and updates to eligibility files
Voto LLC, CVS, Remote Sep 2021 – Jun 2022
Claims Analyst
Receive claim assignment, confirms policy coverages, and directs acknowledgement of claims within multiple states such as AZ, NJ, PA, CA, TX for contract Appeals and Grievances and resubmissions/reconsideration of payment according to CMS guidelines.
Interprets and makes decisions using independent judgment on moderate difficulty claims and policy coverages and determines if coverages apply to claims submitted.
Update tracking system of provider disputes and appeals.
Properly distinguish between a provider dispute and a provider appeal and generates a provider appeal.
Investigates, evaluates, and adjudicates first and third- party claims to determine validity and verify extent of damage by telephone contact with clients, claimants, witnesses, or other parties as required.
Work on QNXT system verify information for Appeals/Grievances, Call Tracking, Special Projects for system updates of Provider Contracts. Medicaid, Medicare and OIC COB other member insurance.
Receive claim assignment, confirms policy coverages, and directs acknowledgement of claims.
Revenue Cycle Management for Medicaid/Medic; AS400 Administrator are accounts verify HIPAA - TPL, COB and Other Insurance OIC information needed to finalize in processing of Provider Claims.
Interpret and make decisions using independent judgment on moderate difficulty claims and policy coverage and determines if coverage applies to claims submitted.
Investigates, evaluates, and adjudicates first and third- party claims to determine validity and verify extent of damage by telephone contact with clients, claimants, witnesses, or other parties as required. Worked on EPIC systems. Verification of Prior Authorization for payment and processing/adjustment/adjudication of all claim types from UB04 t* HCFA 1500 – Medical and Medicare claims.
The Structure -Molina Healthcare, Remote Jun 2020 - Apr 2021
Provider Relations Contract
Responsible for network development, network adequacy and provider training and education, in alignment with Molina Healthcare's overall mission, core values and strategic plan and in compliance with all relevant federal, state, and local regulations.
Provider Services staff are the primary point of contact between Molina Healthcare and the contracted provider network.
Network management entering enrollment and eligibility information to ensure current updates for the appeals and grievance departments knowledge of and compliance with Molina healthcare policies and procedures customer service.
Worked on QNXT systems and CISCO ASA system office phone lines.
THE JUDGE GROUP- Agilon Healthcare, Anaheim, CA Jan 2020 - Mar 2020
PDR Claims Analyst/Specialist
Research and evaluate contract terms/interpretation and complies necessary supporting documentation for the resolution of provider disputed claims under the PDR Department Provider Disputes and Resolution department.
Respond to incoming provider disputes accurately, timely and in accordance with all est. regulatory guidelines.
Process/adjudicate and notate the claims accordingly within the claim systems.
Update tracking system of provider disputes and appeals.
Properly distinguish between a provider dispute and a provider appeal and generate and/or escalate a provider appeal for payment.
Provide Interest and Penalty updates to previously paid claims per CMS Audit of claims within the VANTAGE and LAMC accounts of MEDICARE and MEDICAL Health Plans
Work on FACETS system for claim processing.
Artech, Kaiser Pasadena, CA Jun 2019 - Sep. 2019
Enrollment Specialist
Collaborated with Practitioners and Facilities within government programs.
Assist the Provider and Facility Enrollment Coordinator and Management with Unit production.
Enroll and terminate providers, practitioners and facilities with CMS and other government programs by completing 855 series forms.
Gather credentials and associated documentation required for enrollment and process enrollment forms.
Track status of in process enrollment forms until final approval received.
File provider/practitioner/facility ID numbers once assigned by governing agencies and perform system updates as appropriate.
EPIC
Maintain forms that meet standards for Credentialing of state and federal legislation and accrediting body standards.
Partner with MAPMG and Health Plan Human Resources and Practitioner and Provider Quality Assurance to research and process internal or external requests regarding provider/practitioner license, credentials and assigned ID numbers.
Follow up on claim denials related to enrollment issues.
Work on PECOS and PAC System, EPIC and Tapestry and edit under Microsoft, Excel and Power Point, Word Documents for Credentialing of Kaiser Employee (Medical and Professional).
HCT, Agency Cal Optima Healthcare Orange, CA Oct 2018 - Mar 2019
Claims Specialist Recovery
Recoup and retrieve claims payments made in over payments to accounts and erroneous service codes.
Hospital and professional services payments made to provider accounts.
Benefits and eligibility verification as well as CPT/ICD 9 and 10 checks to provider accounts made in error recovery.
Followed established policies and procedures to use available resources such as provider contracts, Medicare and/or Medicaid guidelines and Member Evidence of Coverage (EOC) to process and adjust routine assigned claims in an accurate and timely manner.
Performed payment reviews and adjustments due to retroactive effective date of contracts and/or fee schedule changes.
Participated in system testing and communicates newly identified and potential issues to the Claims Supervisor and/or Manager.
Attend and actively participate in daily, weekly, and monthly departmental meetings, training, and coaching sessions.
Resolved claims payment issues as presented through Provider Dispute Resolution (PDR) process and/or provider calls.
Maintained productivity and quality standards as defined by Management.
Communicates with other departments to resolve provider claims related issues.
Contacts providers either telepathically or in writing for additional information to resolve or clarify submitted claims issues.
Managed misdirected claims inquiries phones and mail.
Systems utilized for Claims Edit and Project Management under FACETS systems.
Worked Project Management teams for SQL; Agile and Pivot Tables update /configuration for systems QNXT; Facets and Epic .5 and .4 editions versions applications
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