Review and research claim issues from provider's and or provider representatives. Work with the claims department in the payment of claims and issues that need special attention. Work with State Complaints that are received. Advise provider reps with questions and guidelines. Utilize Excel, Amysis system, an excellent knowledge of Medicaid Guidelines. Auditing the processed issues to insure accuracy. AuditorWork with providers that require audits to assure that claims are being paid according to the provider's contract. Work with several areas within the company to assure quality to the provider's claims payments. Sit on conference calls with the provider to hear the problems and work through each of them. Audit problem provider's claims prior to payment being issued to assure quality and correct payment.Referral SpecialistsAnswer and handle intake calls. Pre-certify hospital stays. Manage that all faxes, pre-certs and prior authorizations are handled in a timely manner and are sent to the correct nurse. Speak with providers of hospital and physicians offices to address authorizations and any additional issues and follow-up necessary to complete the providers/insured's requests. Manage the in-network providers and guide the patient and or the patient to utilize in-network providers. Make sure current information is correct for providers. If information is incorrect be certain that all information is obtained and corrected. Work to educate the insured of the use of in-network providers and help them find the correct providers within their network. Send out materials such as provider booklets, etc to help them make the appropriate decisions in choosing a provider. Work directly with the nurses. Send out denials from the nurse case manager. Knowledge of Medicaid Guidelines

Handle pre-determinations, appeals, and insurance department complaints. Work with the nurses and physicians. Review and answer analyst questions. Review high dollar claims and advise on medical necessity. Work with the Account Managers and Client contacts on appeals, employee complaints. The liaison between EBMC and the client. Work and attend fraud meetings and conventions. Apply HIPPA and ERISA guidelines. Follow Plan specific Summary Plan Descriptions. Handle inquires from insured's and providers. Work on internal guidelines for claims payment.

Selected for assignment an in Nova Scotia based on high performance, to train individuals on Proclaim system. Handled high dollar claims to insure accuracy. Review and pay stop-loss claims. Worked many special reports for the supervisors, managers and directors to keep claims adjudication within correct turn around time. Worked with trainees doing chair side coaching to enable the use of all tools available to achieve production/quality goals. Knowledgeable in PPO, Managed Care, Medicaid, Medicare. Use of CPT, ICD9, REV codes, HCPCS. Have processed hospital, medical, dental, psych, RX claims at the Tier 1, Tier 2 and Tier 3 levels. Worked at home independently for 8 years processing claims.

Paid claims in a timely manner, following company guidelines. Worked with other processors to be sure they handled all claims payment accurately. Handled calls and resolved issues from insured's and providers. Maintained quality standards of 100%. Maintained all reports for production, quality and process improvements. Worked on company's computer paying claims until DAI withdrew from the insurance industry, at which time claims were paid manually for the run out. CONSULTANTS AND ADMINISTRATORS

Worked remotely from home paying health claims. This required payment of claims on line per policy provisions. Continually carried production and quality standards of 100% and above. Used knowledge of CPT codes, ICD9 codes, PPO, multiple surgeries, hospital pre certification review, payment of hospital, medical, and dental claims for group and individual policies for a third party administrator.

Paid claims on line per group contract, utilizing all above procedures and policies as at DAI and Consultants & Administrators. In 1986 was promoted to Reconsideration Specialist. This involved problem solving for customer service representatives, examiner errors and insurance department complaints. In 1987 was promoted to Assistant Supervisor. Duties included monitoring production, quality and training for twenty claims examiners and five pre-processors. Responsible for weekly, monthly production reports, quality reports, solving problem claims and authority to work with high dollar claims.