Research, analysis and adjudication of all claim types with varying ranges of complexity. Review of provider appeals and documenting outcome determination via correspondence. A provider liaison for claim issue resolution by utilization of appropriate corporate functionalities. Adheres to company based quality and production standards

As a Human Resource claims specialist. In this position I assess eligibility, collect & review documentation, and create Leave of Absence claims for employees. Provide case management through completing related tasks & correspondence to employees on case activity. Troubleshoot issues regarding Payroll, Time off, and Employee status. Maintain compliance on procedure changes.

Working in the SIU (special investigations) department. In this position I use data analytics to build cases and create referrals. These are used to determine a provider's possibility of Fraud, Waste and Abuse practices. I create notifications (flags) for providers to ensure proper adjudication for incoming claims. I notate and re-adjudicate claims upon review completion of Provider documentation. Also complete special projects upon changes in provider status. Daily use multiple systems & databases.

Having thorough up to date knowledge of coverage criteria for public Healthcare Exchange insurance plans. Inputting and processing medical claims for members. Abiding by CMS compliance guidelines

Informed members of insurance plan details and advised of coverage options. Provided accurate information regarding providers and coverage criteria. Adjudicated medical claims and informed of appeal options.

Sold insurance plans for Aetna Medicare primarily Medicare Advantage plans and standalone Prescription Drug Plans