Emily Evans Email & Phone Number

Maple Heights, Oh, Us

Ohio, United States

Liaison between Provider Relations and the Health Plan, reviewing claims inquiries received, which consist of Professional and Institutional claims received from Providers for correct processing, determine the root cause and adjust claims as needed. Sending the resolution to the Provider Relations Representative to communicate to the providerCreate excel spreadsheets for large claims projects to be sent to the claims department or scripting for reprocessingCoordinate efforts with other departments to ensure resolution/response to internal and external inquiries were resolved in accordance with guidelines, such as provider appeals and disputesRespond to Department of Medicaid Services Complaints in a timely manner. Providing Root Cause Analysis and resolutionReview the Catastrophic Cases for finance to determine if highdollar balances should continue to be accrued

Ohio, United States

Liaison between providers and the their provider relations representatives to respond to and resolve claims processing concerns.Create Excel spreadsheets to send to the adjustments department for processingRun reports in Access Database to gather information for claims analysisAudit provider records during the credentialing process for accuracy

Create Excel spreadsheets to send to the adjustments department for processingRun reports in Access Database to gather information for claims analysisReview projects returned from the adjustments department for accuracyAudit provider records during the credentialing process for accuracy

Manager ClaimsPerformed such duties as evaluating employee performance, pay adjustment recommendations, training, time and attendance tracking, corrective action proceedings, interviews and candidate selection, and establishing goals for the department.Ensured handling of all responsibilities associated with claims processing were timely and in accordance with State and Federal regulatory requirements.Provided direction and guidance to Unit Leaders and Claims Staff regarding special/difficult issues requiring advanced knowledge.Coordinated efforts with other departments to ensure resolution/response to internal and external inquiries were resolved in accordance with guidelines.Provided comprehensive reporting on unit performance.Operations Adjustment LeadParticipated under minimal direction in broad and varied assignments requiring group plans and company policies and procedures.Responded to internal and external calls regarding operations issues, requiring technical knowledge of specific procedures, i.e. adjudication rules, benefit plans, etc.Provided direction, guidance and assistance to adjustment personnel regarding special/difficult issues requiring advanced knowledge.; Performed adjustments on paid and/or unpaid claims, worked the pended claims reports, answered customer inquiries, sent appropriate correspondence when necessary.Performed financial adjustments including posting provider refunds to corresponding claims, issuing manual checks to providers, making telephone calls to providers when necessary, logging checks onto a database. Benefit Plan AnalystLoaded and maintained benefit plans, procedure codes, ad fee schedules on the computer.Created adjudication rules for claims processing. Assisted Provider Maintenance in loading provider files.Assisted in upgrade and conversion systems.Backup to the Director of Operational Development.

Answered customer request via: telephone, fax and written requests.

Adjudicated medical claims using ICD-9 diagnosis codes and CPT codes.Adjusted medical claims that were adjudicated incorrectly.Assisted in major upgrade to the DISCORP Computer System.Distributed batches of claims to the HMO/Medicaid Unit, responded to examiners questions concerning claims processing.Trained new claims examiners on adjudications of medical claims to ensure proper processing.Assisted in putting together training manual.

Information Technology

Associate Of Applied Business, Microcomputer Application Specialist

Associate'S Degree, Information Technology