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Skills

  • Organization
  • Ethical decision-making in claims
  • Project organization
  • Accuracy in high-volume claims processing
  • Compliance with Medicare/Medicaid guidelines
  • Claims process automation tools
  • Team management
  • Data analysis
  • Relationship development
  • MS Office

Work Experiences

  • Achieved a 76% reduction in turnaround times.
  • Analyzed medical coding and claim submissions for accuracy, increasing approval rates for disputed claims by 60%.
  • Avoided penalties of $11.
  • Collaborated with healthcare professionals.
  • Counseled 4 medical providers monthly on proper billing practices to minimize future claims denials.
  • Developed a comprehensive claims review checklist, improving team compliance by 60% during audits.
  • Delivered training to junior claims adjusters on industry best practices for handling appeals, improving department-wide efficiency by 16%.
  • Conducted root-cause analysis on denied claims.
  • Counseled 15 medical providers monthly.
  • Achieved results within 2021.

Summaries

  • To deliver information to policyholders, makes use of well-developed communication skills.
  • Achieved a $6 payout reduction.
  • Clear understanding of strategic planning and stakeholder engagement as well as project management training.
  • Bringing 14 years of experience in the field, as well as superior vendor management and strategic planning abilities.
  • Created cost-saving initiatives.
  • Contributed to company-wide improvements in operational metrics.
  • Contributed to a 76% reduction in fraudulent claims.
  • Achieved results over a three years period.
  • Achieved savings over two years.
  • Medical Claims Adjuster with 10 years of successful strategic planning and data analysis experience.

Accomplishments

  • Slashed claims decision time by 69% through the adoption of automation tools and process improvements.
  • Oversaw adjudication of claims in excess of $12, maintaining robust records and error-free submission rates.
  • Worked with cross-departmental teams including finance and legal to adjust high-risk claims, successfully avoiding penalties totaling $5.
  • Developed and executed training programs for new team members on claims processing best practices, improving team efficiency by 30%.
  • Trained and mentored 3 junior adjusters on best claims processing practices, improving the team’s productivity by 59%.
  • Resolved 3 claims disputes per week, working with healthcare providers, attorneys, and policyholders to ensure fair outcomes.
  • Achieved Lean to further enhance competency in medical billing codes such as ICD-10, CPT, and HCPCS.
  • Implemented claim review audit workflows, achieving a 27% higher accuracy rate and lower rework costs.
  • Collaborated with team of 2 in the development of procedure.
  • Regularly handled appeals and grievance processes, achieving an overturn success rate of 27%, aiding retention of client business.

Affiliations

  • National Alliance of Medical Auditing Specialists (NAMAS)
  • Fellow, Life Management Institute (FLMI) Certification – LOMA
  • American Society of Safety Professionals
  • Certified Professional Coder (CPC) – American Academy of Professional Coders (AAPC)
  • Toastmasters
  • National Association of Social Workers
  • American Marketing Association
  • Association of Information Technology Professionals
  • Jaycees
  • Project Management Institute

Certifications

  • International Health Coach Certification - National Board for Health & Wellness Coaching (NBHWC)
  • Medical Billing and Collections Certification - program 2022
  • ServSafe
  • Fundamentals of Predictive Analytics in Healthcare - system 2019
  • Certified Case Manager (CCM) - Commission for Case Manager Certification (CCMC)
  • Cisco Certified Network Associate (CCNA)
  • Salesforce
  • Certified Public Accountant (CPA)
  • Certificate in Healthcare Risk Management - Florida International University (FIU) 2017
  • Certificate in Patient Advocacy - University of Miami 2018

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