Network Operations Service Coordinator

AMANDA DORSET

** ****** ****, *********, ** *****

Phone: 732-***-**** Email: **********@*****.***

OBJECTIVE: To obtain a position that compliments my skills and abilities, while providing opportunity for growth. EmblemHealth 2022 - Current

Claims Review Analyst

Responsible for identifying issues with larger impact to members and/or providers to ensure correct application of the Medicaid Benefits as specified by the regulations.

Perform complex and extensive research, analysis, and logical conclusions of paper and electronic claims to resolve disputes by providers/members.

Accountable for coordinating the resolution of claims issues by actively researching and analyzing systems and processes that span across multiple operational areas.

Complete thorough end to end multiple issues analysis to determine root cause for breakdown and identify appropriate course of action for resolution.

Horizon Blue Cross Blue Shield of New Jersey 2010 - 2021 SR. PROVIDER FIELD CLAIMS COORDINATOR, PROVIDER SOLUTIONS TEAM

Facilitated and participated in provider seminars to ensure coverage of all claim issues/concerns, as well as providing onsite support in the physician’s office two to three times a week on an as needed basis.

Coordinated with Network Operations to research, recommend, and develop procedural, systemic and/or other revisions to increase departmental efficiency, accuracy, and productivity in the Service Division.

Responsible for data trending and providing analytical reports to Network Operations and/or the provider community.

Horizon Blue Cross Blue Shield of New Jersey 2002 - 2010 PROVIDER SERVICE COORDINATOR/REPRESENTATIVE

Coordinated administrative claim appeals on behalf of members and/or providers by interacting with medical and case management personnel to provide information and resolve administrative and systemic issues. In addition to providing timely and accurate service to our provider network

Performed routine research related to claim history, contract benefits, and system guidelines to determine duplicates, under payments, or receipt of no payment for claim resolution.

Assisted providers with individual claims pricing on professional and facility claims. SYSTEM PROFICIENCIES

TriZetto FACETS, SalesForce, TruProvider, CMS, AAPC, Webstract, Zellis, Evacore/CareCore, Networx, Enrollment Systems, Clear Quest, Microsoft Office Suite, Navinet, UCSW, Cognos, UMWEB, Informatics EDUCATION

2019 Certified Billing and Coding Specialist, Essex County College – Newark, NJ Candidate for Associate’s Degree, Business Administration, Essex County College – Newark, NJ

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