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Career Profile
Key Contributor & Effective Leader with 18+ years of experience in supporting administrative operations within fast-paced and high-stress environments. Significant experience in reviewing complex medical claims, researching client medical information, and leading cross-functional teams. Equipped with a keen ability to improve internal operations and increase efficiency levels. Excel in creating strong relationships with clients, co-workers, and members of the community.
Proficient in: Microsoft Office Suite and EZ Cap 64 Claims Software
Key Competencies
Comprehensive Data Management Training & Development Team Leadership Customer Service
Strategy Development Regulatory Standards Complex Problem Solving Policy Development
Medicare/Medicaid Claim Management People/Performance Management Internal Communication
Professional Experience
Healthcare Partners IPA, Garden City, NJ October 1999-March 2016
Medical Claims Examiner/Adjudicator (2005-2016)
Directed day to day administrative and operations functions within a fast-paced environment with a concentration on increasing productivity and efficiency levels
Play a lead role in examining and adjudicating medical claims using an internal software system in addition to ensuring claim payment deadlines are met
Review medical claims and identify potential duplicate charges in addition to matching claim authorizations with appropriate plan provisions
Maintain an expert level knowledge of regulatory standards related to Medicare, Medicaid, and commercial insurance plans
Utilize superior communication ability to communicate effectively with customers, oversee workflow related issues, and diffuse escalated customer service issues
Support quality assurance functions which include completing detailed audits, reporting errors within 48 hours, and adjusting claims
Data Entry Claims Specialist/Team Lead (1999-2004)
Coordinated administrative and customer service operations within the organization which included entering claim forms into a system prior to claim processing
Supervised a team of approximately 8 staff members and coached individuals on industry specific knowledge such as POS, CPT-4, HCPCS, and ICD-9/10 coding
Generated training materials for data entry staff members, implemented innovative standard operating procedures, and assisted staff members with operational inquiries
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