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Skills

  • Compliance with CMS (Centers for Medicare & Medicaid Services)
  • Handling multi-tiered appeals process
  • Microsoft Word
  • BCCORP W5 for Adjusters
  • Fair Isaac Claims Advisor
  • Appeals documentation system expertise (e.g., Salesforce, SAP)
  • Valuation knowledge
  • CCC EZNet
  • Claims processing Adobe Creative Suite proficiency
  • Cross-functional collaboration

Work Experiences

  • Was in charge of maintaining information files and processing paperwork on a daily basis.
  • Authored the departmental appeals handbook.
  • Achieved results within a three years.
  • Developed positive working relationships with government officials and police officers.
  • Reconciled data in the direct collection system with the accounting system to address discrepancies.
  • Achieved a 52% decrease in escalation rates.
  • Investigated and analyzed insurance claims that appeared to be suspicious or potentially fraudulent.
  • Built strong relationships with external vendors.
  • Analyzed data from method to forecast potential spikes in appeals filings, allowing for better resource allocation.
  • Fixed process codes so that framework claims could be properly classified.

Summaries

  • Appeals Analyst with a passion for personal, property, and casualty losses and damages.
  • Adept at identifying trends in denied claims.
  • Achieved better outcomes.
  • Appeals Analyst known for hands-on claims processing.
  • Appeals Analyst known for hands-on claims processing and cultivating partnerships that led to 21% higher department productivity.
  • Addressed trends to increase approval rates.
  • Achieved Top Performer recognition for forecasting denial trends and proactively addressing issues, reducing future denials by 24%.
  • Criminal investigation, insurance fraud, and surveillance are all part of his background.
  • Adaptable Appeals Analyst.
  • Recognized for motivating management team members to achieve their goals and fostering innovative work environments.

Accomplishments

  • Successfully reconciled an average of 15 claims weekly in Microsoft Excel, increasing overall approval rates by 49%.
  • Implemented an automatic appeals submission system, shortening administrative time by 34% and enhancing resource allocation.
  • Streamlined appeal review process via integration of Salesforce and reduced turnaround time by 15%.
  • Collaborated with medical professionals and insurance providers to ensure compliance with payer-provider contracts, driving a 49% increase in claim acceptances.
  • Documented and resolved process which led to system.
  • Executed quality assurance checks that identified inconsistencies in 4% of cases, driving corrective actions and improving accuracy.
  • Developed comprehensive training materials on medical terminology for new hires, reducing initial error rates by 28%.
  • Collaborated with team of 4 in the development of process.
  • Created and maintained detailed documentation standards for appeals processing, improving accuracy and team-wide compliance by 77%.
  • Led cross-departmental appeals review task force which identified and corrected recurring procedural flaws, decreasing error recurrence by 78%.

Affiliations

  • Association of Information Technology Professionals
  • Lions Club
  • Health Information and Management Systems Society (HIMSS)
  • Society of Human Resource Management
  • American Association of Managed Care Nurses (AAMCN)
  • Case Management Society of America (CMSA)
  • Managed Care Risk Management Accreditation through NCQA
  • Utilization Review Accreditation Commission (URAC)
  • Association for Healthcare Denial and Appeal Management (AHDAM)
  • American Health Information Management Association (AHIMA)

Certifications

  • Cisco Certified Network Associate (CCNA)
  • CompTIA Security+
  • Medicare Appeals Specialist Certification
  • Case Management Administrator Certification (CMAC)
  • Certified Managed Care Professional (CMCP)
  • Associate Compliance Certification (ACC)
  • Cisco Certified Internetwork Expert (CCIE)
  • CompTIA A+ Technician
  • Health Insurance Specialist Certification - Phoenix
  • Salesforce

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