Melissa Hunter Email & Phone Number

Irvine, California, United States

Auditing: • Performs in-depth audits to ensure appropriate coding and system configuration of Medical, Dental, and Visions claims are in compliance with summary plan descriptions.• Research claims processing issues and analyze possible solutions and recommendations.• Perform special project audits as needed.• Knowledge of Electronic Data Interchange (EDI) standardization, medical terminology, claims and billing (ANSI 5010 X12 837 format) information between providers, vendors and payers.• Applies knowledge of pricing RBRVS AB72, QPA and U&C. Utilize Occunet, Valenz, Healthsmart vendors. Works with Anthem as needed to obtain BlueCross data/pricing. Research:• Provide claims department support by identifying and escalating issues related to policies and procedures that may be inaccurate, or unclear and provide recommendations for improvement.• Assess training needs, and provides training assistance directly to Examiners, and sharing expertise to claims staff or other department as determined through audit findings.• Demonstrates effective and professional communication to both internal and external customers.• Assists with claims processing, adjusting, and correspondence as needed. Fraud Waste and Abuse TC3:• Responsible for training, drafting guidelines, communicating, and analyzing claims with TC3 “TruClaim” edits for payment integrity with client Change Healthcare/Optum to review edits (NCCI, MUE, etc.) for FWA. • Provide oversight and support for national coding initiatives edits by external vendor, including daily claim monitoring, review of coding edit results, auditing of claim adjudication post edits, providing additional documentation as needed, and reviewing vendors monthly invoice.• Participation in regular meetings and training with management to discuss trends and claims processing improvement, training programs, as well as policies and procedures.

Chattanooga, Tennessee, United States

Note: Summary of Total Experience with BlueCross BlueShield of Tennessee:• 19+ years claims processing with various BCBST plans (Commercial/Managed Care). Familiar with PPO’s, HMO’s, EPO’s, POS, MCO’s, etc.• 17+ years in claims adjustments.• 9 years as a Pre-Existing Research Expert.• 11+ years Telecommuting.• 5 years Managed Care claim Auditing.• 11/11/2013 - 02/26/21: BlueCare/TennCare Division under the Volunteer State Health Plan subsidiary (VSHP) a Managed Care Organization (MCO). CoverTennessee:• Claims Examiner: 2 years claims processing/adjusting for the CoverKids Child's Health Insurance Plan (CHIP). Promoted to Claims Expert in 3 months.• 2015: Gained Quality Examiner position for CoverKids. Promoted to Quality Expert within 6 months.• Position upon resigning: 02/26/21: Quality Expert for the Training, Education, Audit, and Systems department (TEAS) in BlueCare.

Chattanooga, Tennessee, United States

• 11/11/2013-2015: Cross trained in the Managed Care Organization MCO side of the company as a Claims Examiner for CoverTennessee. I also assisted with adjustment duties and special projects/reports outside of the claims job role due to past experience.o 2014: Pay and Chase/Third Party Medicaid Claims training • 4/2015-10/2015: Was presented with an opportunity to work on a large User Acceptance Testing project for the transition from ICD9 to ICD10 for CoverTennessee. o Purpose: Test claims in a positive and negative way for ICD9/ICD10 codes filed before and after the transition date of 10/1/2015 to ensure claims would handle configuration correctly and if not ensure that it was reported and corrected. My success with this project greatly influenced the reason I gained a Quality position.o Required spreadsheet management of claims cases, status, pass or fail, fine details about the claims, and multiple screen captures for Business Engineering and Analysts.o Log and track configuration requests, apply updates by email communication as needed.

Chattanooga, Tennessee, United States

(CoverKids and BlueCare/TennCare):• Monthly random Supplemental Claim/Adjustment Audits as well as Monthly/Quarterly Focus Audits. • Ability to determine claim errors whether the responsible party is the processor, team, configuration issue, or Online Help is incorrect or a guideline is needed.• Identify targeted claims where education/training may be needed, and encourage performance improvement.• Disagrees were received via email and worked as a priority. At times collaboration with other Quality Examiners, Systems, and Business Analysts is needed. • Ensure that agreed errors are sent to be corrected. • Web Publishing: o 3 years of Dreamweaver web publishing (2015-2018). i. Edited, updated, and published existing web documents, creating new webpages from templates, and archived out of date documents if needed. ii. Managed a general Outlook mailbox to receive Online Help suggestions for possible updates. o 2 years of TeamSite Web Publishing (2016-2018). o After publishing access ended, updates were created via Microsoft Word and submitted to a workgroup review. • Provided cross training, educational emails or shadowing/proctoring to existing or new hire employees as needed. • Organized several Quarterly Claims meetings onsite for three Research Associates for CoverTennessee, to discuss claim trends, issues, questions, training, new updates, etc. • Manage daily spreadsheet for inventory task counting and calculating daily productivity percentages. • Attended meetings and workshops with Business Engineering, IT, Business Analysts, Supervisor and Managers for various projects and performance improvement decisions/suggestions as a CoverKids representative. • Special projects, audits or tasks on an as needed basis.• Inventory and audit totals were managed on shared spreadsheets. • 2017 Trained to audit and process BlueCare/TennCare Claims.• Provide backup support for claims processing/adjusting depending on volume and staffing

• Responsible for researching Quarterly and Monthly reports of claims that have already paid but require a review to ensure the member does/does not have a Pre-Existing condition.• Involved research of members other coverage(s) and their eligibility dates with BCBST, or any other insurance coverage dates on file. Also, the members' hire date, and waiting period for insurance to see if Pre-Existing can be waived or reduced was calculated. • If not waived, further research was required if needed correspondence was mailed/faxed to the provider. • Phone calls were sometimes needed to verify a fax number before sending. • An inquiry was then created and set aside to be followed up within a certain amount of time. • If after several months of correspondence, and if no response came from the provider. Reports would be sent to the Provider Representatives. • Spreadsheets were managed for each report for tracking and status purposes. • Occasionally claim adjustments would be required.

Duties in All Roles:• Providing support to Team Leaders, Supervisors and Managers as needed.• Attended general departmental meetings and workshops as needed.o Also Attended personal or online workshops for Resume Writing, Stress/Time Management, Coaching to Maximize Performance, BlueCard Programs, and Predictive Team Building.• BCBST employees are required to receive annual electronic trainings:o Annual Opioid Training, Compliance, Disability and Inclusion, Inter Plan Programs Staff Comprehension, Civil Rights and Diversity, Security and Safety (Run, Hide, Fight), TennCare Kids, BlueCard Program, HIPPA, Code of Conduct, and Information Security Awareness. • Managed daily emails and determined priorities for daily tasks. • Viewing electronic Explanation of Benefits (EOBs), Member and Provider Remittance Advices, and running web reports if needed. Used Microsoft Access very little. • Use of Blue Squared, a medical records repository used for inter plan claims information between the BlueCross plans. Trained around 2012-2013.Understanding my role in handling and managing Protected Health Insurance Information (PHI) as it applied to my different job positions. Responsible for managing time efficiently. Experience with BlueCross BlueShield of Tennessee:• 11+ years Telecommuting.• 19+ years Claims Processing with various BCBST plans (Commercial, and Managed Care). Familiar with PPO’s, HMO’s, EPO’s, POS, MCO’s, etc.• 17+ years Claims Adjustment/requesting refunds.• 9 years as a Pre-Existing Research Expert for Commercial Plans.

Chattanooga, Tennessee, United States

Entry Level Commercial Claims Examiner for Large/Small Group Commercial employers.• Trained to process standard claims as well as: Coordination of Benefits (COB Secondary Payments for Commercial and Medicare Plans), Pharmacy, Skilled Nursing, Home Health, Rehabilitation and Therapy, Inpatient and Outpatient Care, Durable Medical Equipment, Vision, Dental, Allergy, Emergency, and Behavioral Health claims.• Electronic and Hardcopy claims handling procedures. Includes keying claims from scratch into the claims processing application. Later, trained to process in a paperless Workflow system (which is an automated delivery system in Facets with an electronic route to roles and users).• Was given opportunities early on to handle more difficult claims that were above the current job level. Later was given responsibility to handle specific secondary claims processing and selective groups that only few were allowed to handle. • 2003 – Received formal Claims Adjustment/Recovery Training.• 2004 – Began assisting the Pre-Existing department due to backlog which influenced my transfer later that year. Gained a Pre-Existing position without an interview.

Career Diploma, The Professional Medical Billing Program

High School Diploma, High School/Secondary Diplomas And Certificates