• Audit various areas of the Claims Department including Adjudication and Coordination of Benefits HealthRules claims processing, Coordination of Benefit calls, Revenue and Claims Recovery calls, Explanation of Benefits (Medicare, State, and Commercial), and Document Processing• Ensure accuracy in relation to company policies and each departments’ Standard Operating Procedures• Use of ACL Analytics to run audit file and distribute to the team daily• Run reporting to ensure monthly audit goal is met• Propose process changes to ensure greater accuracy and efficiency• Train and mentor new QA associates in both individual and group settings• Update and develop written department manuals used for training and daily procedures• Serve as a Business Analyst backup performing additional reporting and audits

•Recover money from providers and members through billing processes•Credit Balances, Pharmacy claims paid after member’s policy termination, and Provider Sanctions•Accounts receivable functionality including payment posting and record keeping through database management•Directly handle check and cash payments•Internal and external customer contact •Communication between various departments including Claims, Finance, Pharmacy, and Servicing •Train new associates•Developed training materials by creating Standard Operating Procedures for the Credit Balance process and the pharmacy claims paid after termination process•Claims investigation in HealthRules, Power, and RxClaim

•Coordinating benefits when a member has additional insurance coverage (commercial insurance, Workers Compensation, No Fault, Medicare, and third party liabilities)•Claims processing•Review and work correspondence from providers•Internal and external customer contact•Assist Revenue and Claims Recovery team to recover money for the company•Received training in ACL Analytics

• Direct customer assistance• Train new employees• Delegate duties• Work efficiently as a team to complete duties• Take incoming phone calls to assist with orders and inquiries• Keep area orderly and sanitary at all times