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:

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.

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.
• 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.

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.

• 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.
• 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.

• 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.
• 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.
• 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.

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.
• 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.
• 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.
• 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