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Skills

  • Claims data analysis
  • Problem-solving in high-stress environments
  • Customer service in healthcare
  • Insurance claims software proficiency (HubSpot)
  • Medical claims adjudication
  • Claims Dispute Mediation
  • Quality Control and Assurance
  • Workflow Optimization
  • Coordination with legal and compliance teams
  • Fraud, Waste, and Abuse Identification and Mitigation

Work Experiences

  • Developed training materials and mentored junior team members on interpreting coding systems and making claims processing decisions.
  • Conducted internal reviews.
  • Contributed to revamping the claims adjudication flow.
  • Corrected discrepancies across 17 accounts.
  • Completed project 5% under expected time.
  • Collaborated with cross-functional teams.
  • Conducted audits in 2019.
  • Achieved processing accuracy rate of 15% or higher, significantly reducing claims appeal rates within a 6-month period.
  • Coordinated the adoption of new claims management software, training 8 employees effectively over a month-long transition process.
  • Decreased processing time from 13 days to 7 days.

Summaries

  • Achieved 41% claims approval rate.
  • Adept at using claims analysis to drive improvements.
  • Contributed to the implementation of claims management software.
  • Analyzed claims data to minimize inefficiencies.
  • Adept at enforcing compliance with industry standards.
  • Achieved 31% improvement in claims turnaround time.
  • Cut decision-making times by 31%.
  • Adept at leading audits on high-cost medical claims.
  • Collaborated with underwriting and customer service teams.
  • Accomplished Medical Claims Adjudicator with 9 years of experience.

Accomplishments

  • Collaborated with the legal department to settle 14 arbitration cases, resulting in a 79% reduction in litigation costs.
  • Processed 9 high-cost claims each month, diligently ensuring compliance with state and federal healthcare regulations.
  • Served as the team lead for a project which reduced appeal turnaround times by 9 days, improving the company's ranking for appeal resolution.
  • Reduced claim processing times by 38% through the implementation of streamlined workflows and critical checkpoints.
  • Acted as primary contact for escalations and resolved 35% of cases without the need for external review, reducing operational costs.
  • Developed a decision support tool for processing intricate claims, which resulted in a 32% increase in first-pass resolution rates.
  • Coached 4 new hires on healthcare reimbursement processes, leading to a 41% increase in their claims handling speed.
  • Participated in the design of a new automated claims processing system that reduced data entry errors by 41%.
  • Implemented new fraud detection procedures that resulted in a 67% reduction in fraudulent claims activity within the first 17 months.
  • Managed claims adjudication procedures for process, ensuring compliance with Medicare and Medicaid guidelines.

Affiliations

  • Participated in Medical Claims Trends Analysis webinars provided by standard, applying statistical insights to improve long-term claim outcomes.
  • Certified in Ethical Healthcare Compliance through metric, ensuring claims practices align with legal and regulatory healthcare standards.
  • Member of the National Association of Health Underwriters (NAHU), focusing on health insurance policies and regulatory requirements.
  • Contributor to the Seattle Healthcare Claims Adjudication Best Practices Group, focusing on reducing high-priority claims through improved workflows.
  • Member of the Revenue Cycle Management (RCM) Association, focusing on the latest techniques in payment recovery and claims resolutions.
  • Active participant in the Healthcare Financial Management Association (HFMA) for staying updated on evolving billing and claims processing regulations.
  • Member of the American Health Information Management Association (AHIMA), with a focus on efficient medical record audits for claim verification.
  • Volunteer member of the Health Data Management Association of Portland, assisting with adherence to latest HIPAA guidelines for claims processing.
  • Completed Certified Professional Biller (CPB) course offered by Harbor & Co. To enhance skills in medical billing accuracy and appeals.
  • Attended Medicare and Medicaid Claims Appeals training through system, improving compliance with federal claims processing guidelines.

Certifications

  • Certified Medical Office Manager (CMOM) - Practice Management Institute (PMI)
  • Certified Medical Insurance Specialist (CMIS) - Practice Management Institute (PMI)
  • Health Insurance Portability and Accountability Act (HIPAA) Certification - Brightline
  • Managed Healthcare Professional (MHP) - standard
  • Certified Healthcare Auditor (CHA) - framework
  • Health Insurance Specialist Certification - Northwind
  • Certificate in Health Claims Management - Brightline
  • Certified Revenue Cycle Representative (CRCR) - HFMA
  • Certified Professional in Healthcare Risk Management (CPHRM) – American Hospital Association (AHA)
  • Certificate in Healthcare Compliance (CHC) - standard

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