Claims Manager

Crystal James

*** *. ****** **.

Long Beach, CA *0805

Phone: 562-***-****

E-mail: ********@***.***

Objective:

To find a challenging position with various tasks and responsibilities involving organizational skills, creativity, research and data analysis: utilizing my extensive and diverse medical claims experience.

Professional Experience:

La Vida Medical Group & IPA Inc, Lawndale, CA

Project Manager - November 27, 2007 – Present

• Conduct analysis around various claims payment processes to ensure accuracy of system configuration and provider payments.

• Validate Division of Financial Responsibility to determine payor responsible for claims.

• Prepare Audit Reports and develop Corrective Action Plans (CAP) for the Health Plan when require

• Run, review and submit Monthly Timeliness Report and Quarterly Provider Dispute Resolution Report to the Health Plans

• Interface with regulatory agencies, providers and Health Plans regarding claims related issue, audits and compliance

• Prepare pre-audit check run report, review and complete check run for designated Health Plan

• Help oversee and train Adjudication Staff with processing institutional and professional claims

• Help assist with claim adjudication as needed

• Keep current on all regulatory compliance standards for claims adjudication. Notify appropriate staff of any changes.

• Represent Claims Department in meetings with Health Plans

SCAN Health Plan, Long Beach, CA

Claims Supervisor - November 2002 – November 2007

• Supervise daily work flows of the adjudication staff to ensure timely and accurate processing of denials, provider appeals, ESRD and non-contracted provider claims according to department and regulatory compliance standards.

• Prepare and review performance evaluations. Counsel, train and assist employee.

• Prepare internal and external audits.

• Validate Division of Financial Responsibility to determine payor responsible for claims

• Conduct monthly review of all non-contracted provider claims to ensure timeliness accuracy and regulatory compliance are met for reporting to CMS. Complete Month Timeliness Report.

• Keep current on all regulatory compliance standards for claims adjudication and denials.

Claims Compliance Coordinator - April 2000 – November 2002

• Worked with Claims Supervisor and Lead to train and develop Claims Examiners

• Worked with Claims Auditor to monitor and evaluate performance levels and progress

• Develop, maintain, and update training manuals and policies and procedure

• Conduct weekly audits of high dollar claims

• Assist with claim adjudication

Provider Liaison - January 1999 – March 2000

• Research adjustment and tracer. Adjudicate claims in a timely manner to ensure compliance

• Assist Customer Service with provider calls

• Respond via phone and/or in writing to the providers to resolve claims issues

• Provider feedback to Management and Provider Services of inappropriate trends identified

• Assist with training new staff

MedPartners/Mullikin IPA

Claims Supervisor - March 1994 – December 1999

• Monitor performance of subordinates according to established standards for quantity and quality

• Direct and monitor workflow assignments and daily activities of adjudication staff

• Resolve straightforward day-to-day personnel issues

• Prepare and conduct reports and claims for external audits by the Health Plans

Education:

High School Diploma, Long Beach Polytechnic High

Long Beach City College

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