Enrollment Specialist Team Lead Passport Health/Premera 9/2018 -Present*Represent Eligibility Department on twice weekly client facing meetings for On/Off Exchange clients and biweekly Passport Medicaid meetings. *SME for 834 Files, PCP Assignments, ID Card QA, and Eligibility Issues for On Exchange/Off Exchange and Medicaid clients.*Deep Dive Analysis of ID Card data; creating a more efficient process for members and cost savings for company. *Created trend analysis for ID cards to capture cards not being generated or sent to member, along with unneeded cards being sent due to changes in member’s lob. Collaborated with Technical Operations to update process. * Assist the supervisor and manager in coaching, mentoring and giving constructive feedback to COB and Enrollment Specialists. Includes: assigning workload and following up on productivity goals for both on shore and off shore teams. *Transferred EDI claims experience to create a template for the team to use for reading 834 Data files.

Enrollment Specialist I 8/2017-9/2018 * Updated member records through internal tickets, emails and workflow queue. * Working with the Enrollment team to review 834 X 12 files, resolving any errors. * Created tracking for Daily File Load metrics.* Communicated to client through Assigned and worked Share Point/JIRA Tickets. * PCP assignments. * Training new Hires on workflow queue and 834 file rejections. *Participating in Cross Functional Web Ex and in person meetings.

*Responsible for customer service calls, completion of loss notices, claim data entry, verification of coverage and internal claim referrals. *Initiate subrogation process on claims where another insurance has liability. *Collect information from hospitals, providers and injured parties for bodily injury claims. Confirms billing information and summarizes medical records for legal team.

Electronic Data Interchange - Help Desk - WPS CorporateMedicare MAC J5/J8, VAPC3, TRICARE For Life/TRICARE–Overseas/WPSHI/EPIC/Arise• Respond to telephone and written inquiries from providers, medical billing services and computer software vendors concerning electronic submission concerns.• Receive and respond to telephone and written inquiries regarding PCAce Pro32 software. Serve as primary backup for setup/installation, training and administration.• Review electronic test files for accuracy and completeness using the electronic claim file specifications for each line of business claim filing requirements.

Identify fraudulent practices of providers and beneficiaries with TRICARE For Life.Perform validation audits and obtain case specific data to develop cases to be sentto the Department of Defense. Every case presented to Department of Defense received highest possible rating.Several cases were ultimately investigated by the Inspector General.Consult with providers when claims show a pattern of inappropriate billing,providing claim processing requirements.-Utilize proactive measures such as Pre and Post pay review, Proactive Researchand Data Mining.

TRICARE Encounter Data (TED) records are based on clinical encounters submitted on the UB04 and HCFA 1500. TED records are submitted by the MCSC, audited and claims paid by the Financial Intermediary (FI), and sent to the TED system for final auditing and government payment. -Developed data indicated as “required” in the data element definition not received in the treatment encounter data. -Corrected TED records with claims processing errors, or updated prior data on the record with more current/accurate information. - Resubmitted the corrected Institutional and Non-Institutional TED records that initially failed to pass TMA edits.-Ensured all returned records in a batch/voucher were resubmitted simultaneously. Involved in several projects involving voucher payment information sent to TMA. Instrumental in setting up and maintaining a database to determine payment on vouchers by TMA. The use of this database simplified the process for determining which vouchers were still outstanding, if the voucher was underwritten, and what issues needed to be addressed concerning payment.-Determined if TED records were grouped under the correct Automated Standard Application for Payment (ASAP) account and Contract Line Item Number (CLIN)/ASAP Account. -Ensured the number of outstanding records zeroed out to liquidate or “clear” a batch. -Recorded the ‘active’ date range assigned by TMA for All ASAP Type BATCH/VOUCHER CLIN/ASAP Account Numbers.

Due to staffing requirements I worked for several months in Provider Certification, then as needed.WPS has contractual authority for provider certification and accountability for the TRICARE Encounter Provider (TEPRV) file for providers in our jurisdiction. Upon receipt of a claim or request for provider certification information involving a provider not on the TRICARE Encounter Provider (TEPRV) file:-Certified all providers of care using a single, centralized certification process, ensuring that providers met all conditions in 32 CFR 199.-Contacted the provider, the state licensing board, the appropriate national or professional association, or other sources to determine the provider met certification requirements.-Submitted TEPRV Records via electronic media to TRICARE Management Activity (TMA) for each provider who rendered care to TRICARE beneficiaries. Ensured TEPRVs pass the TMA edits and for performing all maintenance transactions. -Reported additions, deletions, and changes to these files to TRICARE Management Activity. I also worked as needed for Claims Resolution, Foreign Claims and OCR.

Duties included:Daily processing of the cash deposits per TRU guidelinesBalancing cashier tillsProcessing week ending and month ending book work Preparing bank deposits Ordering and processing change from the bank Maintaining Associate files. Employee counseling when appropriate. Maintaining filling system per company policy. I was also involved in loss prevention through Front End monitoring. By auditing register receipts, voided sales and refunds, I was able to be alert to suspicious activites.Key Attributes:Excellent customer service skills High level of accuracy