Claims Processing

 

317-897-6501(h) 317-945-3350 (m) MsFortune54@Gmail.com

 

 

PROFESSIONAL SUMMARY

  • I have 13 years experience in the Health Insurance industry.
  • Experience working with Project Management developing Business Requirements.
  • Experience obtaining business needs through analysis, and interpretation of data. Experience documenting functional specifications.
  • Development experience providing input of alternatives and best for business recommendations.
  • Develop and execute case testing scenarios.
  • Strong analytical and leadership skills.
  • Ability to train on new procedures, as well as effective presentation skills
  • Excellent interpersonal skills. Ability to work independently with minimal supervision and within a team/group environment.
  • Liaison between technical and non technical business associates.
  • Ability to meet required deadlines.
  • Skilled in all lines of business – Professional and Facility claims, Customer Services, Adjustments/Refunds as well as knowledge of the business in order to write Specifications and Business Requirements.
  • Lead BA for the Facets DB project.

PROFESSIONAL EXPERIENCE

Rehab Medical Insurance Verification Specialist                                                              

Durable Medical Equipment (DME) Supplier

  • Responsibilities include but not limited to: Contacting new and existing patient’s insurance carriers to determine benefits and eligibility. Determine if the patient is active and eligible for DME services. Calculate the amount insurance will cover and the patients responsibility. Contact patients to obtain insurance information when not provided or the carrier has indicated they are terminated from the policy submitted. Train and supervise new hires as well as audit their work at 100% until my Manager feels they can work independently based on my feedback. Work with the billing as well as Customer Service departments as well.  

Stewart &Stewart Attorney’s (MRM) Medical Records Management                                                                   

Personal Injury Attorney’s

09/12- 02/13

 

 

 

 

 

 

 

 

06/10- 05/12

  • Responsibilities include but not limited to: sending the initial request for hospital and physician medical records. Once received, the records/ bills are scanned and logged into the needles system. Assist the paralegals with many requests. I am in constant contact with facilities as well as providers office. Handle the HIPAA authorizations as well as many other administrative duties.  

Jacobson Solutions (Consultant)

 Anthem Blue Cross of California- CCOA Cost Containment &

Overpayment Avoidance/Cash Control

 

04/08 –11/09

  • Responsibilities include but not limited to: Handling Provider and Subscriber voluntary and involuntary refunds. Adjusted professional/professional Medicare, Medicaid and facility claims to reflect the correct payment. Adjustments included full and partial credit adjustments.
  • Handled manual check requests due to lack of activity with provider bank account, sub payable, returned due to bad address. Scanned all supporting documentation, submitted a manual check request to the Cash Operations manager. Once the manager approved request was sent to the accounts payable department. Obtained and provided any additional information required by accounts payable department. Once approved by accounts payable mailed live checks out to provider or sub.

DSS (Eli Lilly and Company) Indianapolis, IN   (Contract work)                                   

Medical Assistant

06/07 – 08/07

  • Responsible for mass mailings, data entry, reviewing monitoring reports, communication to investigator sites, maintaining Collaboration Databases. Primary rCDA support clinical trial studies.

Republic Airways Shuttle America Indianapolis, IN

Flight Attendant

  • Responsible for the safety and comfort of customers. Duties involved making customers feel valued and welcome, providing food and beverage service, assisting customers with baggage, helping those customers who are ill or have disabilities, and operating mechanical and safety equipment. Assisted in performing all safety, service and cabin preparation duties

 

10/06 – 02/07

Anthem Blue Cross Blue Shield,  Indianapolis, IN                                                        08/94-06/05

Operations Business Analyst, Operations Trainer, Service Administrator

  • Analyzed and documented business requirements. Worked closely with Project Management. Documented the entire professional and some facility business requirements.
  • Assisted in functional modeling and design.  Produced project deliverables.
  • Lead BA over all of the professional specifications. Lead BA for all professional test case scenarios.
  • Developed and executed system testing. Developed case test situations for different types of claims that pass through the system. Tested and signed off on testing prior to implementation.
  • Trained and assisted end users with the implementation of new technology.
  • Documented functional specifications.  Worked with the programmers to insure accurate results.
  • DB2, Fileaid, CICS and Mercator experience.
  • Worked with SQL, Visual Basic and Cobalt programmers.
  • Lead BA for Midwest provider inquiry and pricing database.
  • Lead BA for Professional and Facility OCR project.
  • Documented and tested Streamline project.
  • EDI and 837 knowledge.
  • Documented enhancements for existing systems.
  •  Responsible for testing prior to implementation 
  •  Provided alternatives and recommendations to director and management team. Provided input and counsel to insure best for business decisions were made.
  • Responsible for training all new Anthem BC/BS associates on FEP Professional claims.  Then selecting and cross training chosen associates on facility claims.
  • Responsible for obtaining and documenting state specific  policy and procedures, Medical policy and FEP specific guidelines for IN, KY, OH,  CO, NV, CT, NH, ME and VA. I was the trainer for all 8 states in which all utilized different provider inquiry and pricing systems. Was responsible for cross training existing associates on system changes and state specific processing changes. Traveled to each state and obtained specific differences as well as learned systems. Documented and cross trained associates to handle each state.
  • Attended the Systems Conference off site meeting each year. Documented year end system changes and trained all associates on upcoming changes for the New Year.
  • Developed on line processing manuals via Robohelp and maintained. Loaded all Medical Policy and FEP specific rules into the Streamline processing system.
  • Responsible for insuring standards of accuracy and timeliness for claims, refunds, and adjustments.
  • Assisted with training and updates; answer claim questions and mentor.
  • Supported the clerical staff.
  • Handled mailroom and image entry issues.
  • Assisted in the image entry contingency plan.
  • Assist with marketing field activities during Open Season enrollment.
  • Instrumental in strategic planning.
  • Assisted with the OPM, LOCCA and CPR audits.
  • Performed claims demonstration for Colorado/Nevada.
  • Assisted with desktop standardization Y2K update.
  • Assisted in the move process to the Lytle Center.
  • Handled five special accounts for irate members.
  • Was a member of the Anthem Safety Team.
  • Was the contact for the help desk and Tag security
  • Assisted with interviews.

 EDUCATION

1996 – 1998    Ivy Tech State College, Indianapolis, IN

  • 3.9 GPA – No degree obtained.

1993 – 1994    Midwest Career College, Indianapolis, IN

  • 4.0 GPA – Medical Assistant

ADMINISTRATIVE SKILLS

  • Appointment scheduling
  • Customer service
  • Microsoft Word, Excel, Access, Project and Visio
  • ICD-9 and ICPT/HCPCS Coding, Insurance Billing, Transcribing
  • Claims processing, adjustments, refunds and voids.
  • 10-key by touch
  • Imaging
  • Claim PRO
  • Lotus Notes
  • Medical terminology
  • CICS
  • WGS (WellPoint Group System)
  • TPX
  • Streamline
  • Diamond
  • Facets
  • ACES
  • AIMS
  • Amisys
  • Genesys
  • Business Objects
  • Needles
  • Lazarus
  • Endeavor
  • Connex
  • Brightree

CLINICAL SKILLS

  • Patient Preparation
  • Vital signs
  • EKG’s
  • UA, Labs, venipuncture
  • Injections
  • CPR/First Aid
   

 

 

 

 

 

 

 

 

 

 

 

  • ID#: 70582
  • Location: Indianapolis, IN , 46236

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