Claims Processing Analyst

Bennette O’Cana

719-***-**** *******@*******.***

PROFESSIONAL SUMMARY

Detail-oriented Claims Analyst with extensive experience in claims processing, adjudication, and appeals. Proven ability to investigate and resolve complex claims efficiently while ensuring compliance with regulatory standards. Skilled in collaborating with providers, vendors, and internal teams to streamline operations and enhance accuracy. Adept at utilizing claims management systems and analytical tools to drive efficiency and minimize errors. Looking to leverage analytical and problem-solving expertise in a dynamic role that values accuracy and operational excellence.

AREAS OF EXPERTISE

Claims Processing & Adjudication Appeals & Dispute Resolution Compliance & Regulatory Standards

Investigative Research Contract Benefits Analysis System Testing & Upgrades

High-Value Claims Management Team Collaboration & Leadership TECHNICAL SKILLS

Zelis Burgess HealthEdge Diagnostic Codes (CPT, ICD9/ICD10, REV) CMS 1500 Excel Outlook Teams Provider Contracts COB Processing Audits PROFESSIONAL EXPERIENCE

Exam Resources

April 2023 – March 2025

- Assisted in the liquidation of Friday Health Plans, ensuring accurate claims processing and resolution.

- Managed claims appeals, providing detailed reviews and justifications to support resolutions.

- Conducted in-depth research on provider inquiries to ensure compliance with contractual agreements.

UST Global

July 2023 – March 2024

- Allocated as a temporary employee for the UST/HCPS-OLBP project, supporting Friday Health Plans’ liquidation process.

- Collaborated with internal teams to resolve outstanding claims and disputes efficiently. Friday Health Plans (Acquired Colorado Choice)

2007 – 2023

Claims Analyst Tier III

- Adjudicated and processed physician, hospital, and dental claims using HRP system reports, ensuring compliance with industry and regulatory standards.

- Successfully processed high-dollar claims with a focus on accuracy and timely payments.

- Conducted system testing for new claims processing functions and upgrades, contributing to improved system performance.

- Resolved escalated claims and provider disputes through thorough analysis and communication.

- Reviewed and interpreted contract benefits, audits, and regulatory requirements to facilitate accurate payments.

- Coordinated check run files for vendors and ensured claim payments aligned with service level agreements.

Colorado Choice (DBA SJV HMO), Alamosa, CO

1999– 2017

Claims Analyst

- Entered and processed claims using Express systems, ensuring adherence to industry standards.

- Adjudicated UB-04 and CMS 1500 claims, maintaining high accuracy rates.

- Managed internal and external reporting for claims data analysis.

- Conducted pre-check run audits to verify claims accuracy and minimize discrepancies.

- Evaluated out-of-pocket costs, co-insurance, and co-pays before finalizing check runs.

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