Claims Examiner Data Entry

KAREN MAHONES’

**** *** ****** ****, ******** Ga 30068

Cellular: 404-***-****

email: ***********@*****.***

Summary:

Claims Examiner with several years of experience handling Medical, Dental and injury claims examiner. Able to handle assigned claims following company guidelines and industry best practices with a minimal amount of supervision. Thorough understanding of coverage interpretation and litigation. Comfortable performing other tasks and duties within claims departments as dictated by business needs.

Key Qualifications

Licensed claims adjuster for SC, NC, Ok, and Home state is Florida

Outstanding Knowledge of claims processing and medical terminology

Superb data entry skills with high accurateness

Strong written and spoken communication skills

Good computer skills

Medical Insurance & Dental insurance Knowledge

Excellent Interpersonal Skills

Excellent Phone Skills

Various Practice Management Software

Records Organization & Management

Online Claim Submission & ERA Remarkable experience in processing medical claims.

Good understanding of medical terminology, HCPCS, PDR, CPT and ICD-9 codes Extensive

Party liability and coordination of benefits claims

Ability to analyze claims, set reserves, determine compensability and settle claims

Ability to resolve difficulties quickly Ability to make

Time Management

Judgment and Decision Making

Policy investigations

Critical Thinking

Complex Problem Solving

Negotiation

Negotiation and medication skills

Microsoft office Suite

Coverage determination

PROFESSIONAL EXPERIENCE

STATEFARM AUTO INSURANCE July 2022 to Present

Injury Claims Examiner

Investigates, evaluates, negotiates, and settles auto claims in an assigned area to include verification of coverage, legal liability and extent of damage to persons and property, which may necessitate interaction through phone, e-mail, in-person, or different electronic media.

Applying knowledge of policies, and insurance regulations when determining coverage, liability, & damages

Investigating, evaluating, negotiating, and settling claims.

Evaluation of body injury claims with medical review and determine if MOI is a contributing factor.

Communicate claim action/processing with insured, client, agent when appropriate.

Contacting customers by telephone, written correspondence and/or various electronic media.

Supporting our customers through personalized, caring

Effectively managing work through task driven queues while multi-tasking in a fast-paced call center environment

Addressing injury claims, and negotiation of settlement,

Property Damage evaluation.

Littigation with Opposing council and Company Attorney’s

Identifying and pursue subrogation and risk transfer opportunity.

IPG Claims Property – Part time Sept. 2021 to January 2023

Conducted prompt and thorough investigations to determine policy coverage

Evaluated facts of the loss, and interpret state and/or federal laws and regulations

Carefully reviewed all claim information to ensure accuracy, and avert fraudulent claims

Provided customer service to policyholders, third-party administrators, and public adjusters

Collaborated with field and independent adjusters to assess damages

Produced documents throughout the claims process

Obtains information from involved parties to evaluate facts of loss, including law enforcement reports, witness interviews, to determine liability. Reviews coverage and claims process with customers. Sets reserves, assigns material damage features for inspection.

Researches and responds prompt to customer inquiries and/or concerns throughout the life of a claim to ensure customer satisfaction and retention.

Identify and escalate files with more significant indemnity exposure or attorney representation to supervisor for review/transfer for further investigation.

Negotiates, settles, and authorizes payment for property loss claims

Kindred at Home

Marietta, GA 30066 June 2018 to Dec. 2022

Eligibility/Authorization Team Lead

Eligibility & Auth Team Lead

As an Insurance Verification Team Lead, I was responsible for timely and accurate insurance verification as well as accurately interpreting managed care contracts. And obtaining authorization for home healthcare services to be provided to patients.

Subject matter expert in completing the Prior Authorization process with insurance companies and practitioner offices.

Acts as subject matter expert in completing a full Medical Verification for all Home Healthcare services to be rendered.

Follows scripted benefits verification format in proper systems custom benefits screen and record benefits.

Verifies patient insurance coverage for home health care service.

Working with Home Care Home Base.

Contacts physician to resolve issues regarding prior authorization or referral forms.

Perform electronic eligibility confirmation when applicable and document results.

Research Patient Visit History to ensure compliance with the Medicare 72 hour rule.

Completes Medicare Secondary Payor Questionnaire as applicable for retention in Abstracting module.

Performs insurance verification and account status changes by assigned facility.

Communicates with hospital-based Case Manager as necessary to ensure prompt resolution of pre-existing, non-covered, and re-certification issues.

Utilizes system account notes and Collections System account notes as appropriate to cut-n-paste benefit and pre-authorization information and to document key information.

Perform Insurance Verification activities based on production quotas. Fully capable of meeting quotas.

Aid supervisor with leading the team including covering the team when the supervisor is out of the office.

Knowledgeable of the duties required of the Revenue Specialist

Assist with training and coaching able to give constructive criticism when needed

Assist with Quality Assurance

Flexibility and willing to work overtime when needed

Homeowners Association Coordinator February 2019- May 2019

Firstkey Homes, Marietta, GA

Temporary Assignment

Represented company on all related HOA matters within assigned regions.

Processed Homeowners association dues and legal invoices.

Input invoices into AX system and prep for accounting.

Allocate invoices to proper properties and document within the database.

Ensure there are no duplicates and/or overpayments.

Remain prompt with paperwork processing to ensure vendors are paid in

a reasonable amount of time.

Communicate clearly and concisely with details to internal team as well as external vendors.

Delta Dental August 2013-Dec. 2018

Claims Examiner 11

Reviewed claims to ensure compliance with established claim entry and claim payment policies and procedures.

Processing of, dental claims from health plan members, contracted and out of network providers using related Metavance systems and applications.

Aid in manual claim entry and member reimbursement.

Complete claim adjustments request per provider, member, as well as contact center and QM request. Responsible for the researching and processing of all adjustment requests, and ensuring correct benefits and policies are applied according to contracts and policies.

Maintaining standardized productivity, accuracy and quality performance standards for claims processed.

Skilled use of Metavance systems and applications for provider network and member data, utilization management, claims adjudication, and customer service.

Processing of, dental claims from health plan members, contracted and out of network providers using related Metavance systems and applications.

Kaiser Permanente August 2013 – August 2014

Customer Service Member Associate 2

Temporary Position

Responsibilities

Responded to member’s questions and concerns and act as a member advocate for their service, needs, and interest within KPMCP. Resolve issues at the lowest possible level. Assure smooth transition from purchaser to consumer through implementation of service strategies within the Call Center. Work with MSA/CSA to resolve member problems.

Provide information and support to members and internal and external customers regarding contracts/benefits explanation and clarification.

Identify, investigate and communicate to Medical Center managers and staff service issues relevant to MSA/CSA. Ensure that information needs and service issues are resolved in a timely manner.

Input data and information generated through the Call Center ensuring the format is understandable and actionable (such data may consist of information relating to members' needs, consumer perceptions, etc.).

Track all inquiries and requests on an automated contact management system.

Provide linkage of grievances and facility service issues and inquiries to appropriate department and acknowledge complaints to members through computer generated correspondence.

Diffuse anger, tension or hostility some members feel when dealing with issues that significantly impact their own health. Effectively communicate the care and concern that Kaiser Permanente has for each member.

Global care/Temporary Assignment April 2012 – August 2013

Savings Coordinator/Workers Compensation Claims Processor

Alpharetta, GA

Responsibilities

Ensured to process assigned claim forms and inspect apt allocation of co-pays, deductibles, reimbursements and co-insurance.

Maintained written record of phone calls in system and adhered with issues as required.

Analyzed and processed workers’ compensation claims by investigating and gathering information to determine the exposure on the claim

Negotiated settlement of claims up to designated authority level.

Processed complex or technically difficult claims.

Calculated and assigned prompt and appropriate reserves for claims and continued to manage reserve adequacy throughout the life of the claim.

Worked with workers compensation, disability and leave.

Worked with insurance Carrier/TPA data and claims management systems to analyze loss data.

Managed the day to day administration of the Workers Compensation Program.

Working with Third Party administrator (TPA).

Provided the day to day oversight management of the TPA interacted with employees.

Healthcare Management Inc. June 2004-May 2010

Call Center Manager/Patient Account Manager

Baltimore, MD

My role as Call Center Manager

.

Directed call center operations as a liaison between clients, supervisors, and call center employees. Administer performance management by diagnosing improvement opportunities, providing effective feedback, coaching, training, professional development, and corrective action plans. Reviewed call center statistics to measure staff performance and the need for improvement.

Developed sales techniques of each customer service representative to drive revenue growth.

Coordinate the interviewing, hiring and training of over 21 customer service representatives. Monitored interaction between staff and callers to ensure quality assurance standards.

Performed quality checks, develop and review performance reports, identify areas to improve, and implement measures to improve performance levels and meet objectives. Conducted group training sessions on financial products and services.

My Role as a Patient Revenue Cycle Manager

Handled appeal denials and rejections, all billings and collections related to the various funding entities.

Interacted with patients to answered any financial questions and set financial arrangements as needed.

Organized and supervised the billing department.

Posting and electronically daily charges as well as posting payments.

Produced and tracking accounts receivable reports and trained staff on coding both ub92 and hcfa1500.

Met accounts receivable operational standards by contributing information to strategic plans and reviewed; implementing production, productivity, quality, and customer-service standards; resolving problems; identifying system improvements.

Maxim Healthcare Services August 2001 - June 2004

Patient Account Manager/Medical Biller Columbia, MD

Responsibilities

Improved revenue for most recent provider over 32% with same patient load

Post and reconcile insurance and patient payments. Research and resolve incorrect payments, EOB rejections, and other issues with outstanding accounts

Insured accuracy of insurance claims. Verify correct ICD-9 and CPT codes for a variety of specialties.

Set up new patient accounts

Assign ICD-9 to physician’s diagnosis and insure correct level of service and various other CPT codes.

Set-up practice management software for submission of electronic claims to clearinghouse.

Worked with clearinghouse to resolve file compatibility issues.

Retrieve Electronic Remittance Advice (ERA's)

Send secondary claims upon processing of primary insurance

Monthly processing of Patient statements. Answer and resolve patient billing inquires

Follow up on Insurance and patient aging. Re-submit insurance claims as needed.

Knowledgeable in timely filing restrictions.

Integrated Health Services July 1997 – August 2001

Medical Claims Examiner

Responsibilities

Reviewed and adjudicates health related claims based on policy provisions and established guidelines.

Requested additional information from members and providers as needed.

Initiated and completed claim investigations when indicated including pre-existing conditions, accidents, medical necessity and appropriateness, eligibility and coordination of benefits.

Documented fully claims referred to senior staff for review and determination

EDUCATION

American InterContinental University Atlanta Campus

Bachelors in Business Management 2005

CERTIFICATIONS

PROFESSIONAL ASSOCIATIONS

North American Call Center Management Society

PROFESSIONAL DEVELOPMENT AND EDUCATION

Customer Service Diploma, Arlington Technical Institute, 2000.

Conflict Resolution and Negotiation Certificate, Seattle Technical Institute, 2000

ADDITIONAL TRAINING

Secretarial Studies, Crown Business Institute Grievance Handling, 2001

Customer Service Series 1, 2 & 3 Adverse and Conduct Based Actions, 1991

Diversity Workshop; Conflict Management Basic Employee Relations, 2001

Team Leadership\Adult Education /Management 2007 Customer First 2006

Superior Customer Service (CCBC) 2009

Seminar for New Managers; 1995

People Soft Training 2008

Instructor Training; 2005 Yardi Training 2008-2009

ADDITIONAL SKILLS

Microsoft Word, Excel, Power Point, Data Management Systems, Typing Speed 75 wpm. E-Recruit, Lawson and PeopleSoft Programs. Yardi.

Volunteer Opportunities May 2011 – December 2012

American Cancer Society,

White marsh, MD

Our Daily Bread as a Career Services Advisor working with the population of

Baltimore City and County.

Licenses: NC. SC, OK and Florida is my Home state

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