AILEEN TYLER
Summary
Highly motivated individual with great customer service experience with outstanding telephone skills and extensive knowledge of processing medical claims and researching resources. Empathetic Care Worker with sensitive and compassionate approach to cultivating trust.
Overview
34
34
years of professional experience
Work History
CAREGIVER
DIRECT
Phoenix, AZ
- Provided care for elderly patient
- Cooked and served meals
- Checked vital signs, administered medicine, and kept daily logs
- Transported patient to appointments and errands
RESEARCH ANALYST III, AUTHORIZATION ANALYST
- Identified trends in provider issues to aid provider relation unit
- Received inbound and made outbound phone calls to assist provider with payment issues
- Responsible for creating and processing special project requests
- Processed pharmacy and dental claims, including: HFCA1500 and UB92
- PRIOR, Created telephone prior authorization requests via online system
- Knowledgeable with ICD9, HCPC and other procedure codes
- Processed mail requests in a timely manner
- Gathered medical documents for review
- Assisted medical utilization unit
- CUSTOMER SERVICE REPRESENTATIVE III
- Provided accurate information to members and providers
- Identified member issues and provided quick resolutions
- Conveyed information with clear reasoning and supportive decisions
- Documented all written communications
- EDUCATION
Associate Testing Analyst, TPL Admin., Check Trace
Finance Department
Phoenix, AZ
02.2016 - 08.2022
- Testing/ TPL
- Third Party Liability -The MBU Mailbox, has all incoming emails and attorney letters that need to be reviewed and directed to other entities like FRG, DMAS, and HMS facilities
- The Claims History request are a 24 hour turn around request
- That you have to do a report of the requested member and gather data of all the claims that requested in a date range, format in in PDF spreadsheet and send secure back to the requester
- Assigned to Special Project for Kentucky
- This project had a monthly deadline, by the time of the deadline the spreadsheet has to identify who payment was received by
- If same payment was made multiple times and how was payment going to be returned and logged
- Negative balances, The Health Plans sends a spreadsheet thru email requesting the negative balances be transferred
- You must go thru Finance department in QNXT to review the provider account that you are transferring from
- You then make the transfer following the formula that already set up
- Then you will need to follow the same steps in QNXT as far a s reviewing the correct provider's account and reviewing the email to ensure that you are applying the correct amount to the correct line of business and or the correct provider
- I do Write offs and adds to negative balances if requested, which these 2 steps are part of transfers as well
- Bankruptcy report
- This report comes from Finance department and you need to check the highlighted provider
- You run the provider ID number thru every Health plan in QNXT to see if they are listed in the system
- If they are you will need to provider the requested information, there are many fields that are asking certain information pertaining to bankruptcies
- My input was used to update the procedures for the process
- She assisted in updating the TPL policies prior to moving from that team
- Develops and executes comprehensive testing processes for system enhancements and new products and processes encompassing all aspects of customer service including claims, enrollment, provider contracts, and benefits administration
- Responsible for creating and executing defined unit testing processes to provide quality audits for vendor contracts prior to implementation
- Assists with testing simple system enhancements
- Prepares and executes a comprehensive test plan and test scripts to provide quality audits for vendor contracts to ensure quality and accuracy is maintained
- Verifies that system functions according to user requirements and conforms to established guidelines
- Follows standardized best practices for documenting and executing simple to moderately complex test plans
- Validates test results, documents discrepancies, and follows through with resolutions to ensure all issues are resolved
- Reports progress of problem resolution to management
- Communicates test outcomes to end users for sign-off on the results
- Serves as liaison between the system end users and the IT team
- Performs other duties as required
- EOB Sampling- Where to run multiple queries for 17 health plans for other Insurance, you are randomly sampling all payments to see if other insurance has been applied
- This would be done Once a month
- I also had to send outcome of test to all health plans
- Ad Hoc have very straight guidelines that need to be followed timely as far as every Wednesday by 2 pm the request must be sent to Supervisor/, Ad Hoc- are check from QNXT system that needs to be reissued, many times it can be voided, and the associated claims will be reprocessed during the next check run
- There are a few instances when this process won't work, and we will need to generate an Ad Hoc (or manual) check:
- Generate a spreadsheet for 17 health plans using the “Data Loader Template pasting information from
- QNXT or another document, Match Destination Formatting, Values & Number Formatting
- Working with
- Multiple provider checks and adding them to the spreadsheet
- Complying request of emails for Ad Hoc creating a spreadsheet with attachments and letter for corrected checks, once checks arrive to office, I would need to update QNXT with Ad Hoc memo, create envelope and mail them to providers with attachments that were sent with request
- Claim Reporting and Processing specialist check tracer analysts: when a check payment have not been received or cashed a check tracer request will be placed and researched by checking with the bank to make sure check has not been cashed
- If confirmed by processes, research and the bank confirmation then a stop payment and void will be requested and reprocess of check thru claims check run will generate new payment to go out.
CLAIMS PROCESSOR
COVENANT CONSUMER
06.2014 - 06.2015
- Compiled claims reports
- Processed claims with 98% accuracy with high-level of productivity
- Assisted with time sensitive special projects within the department
CLAIMS ANALYST III
HEALTH CHOICE ARIZONA
05.2008 - 08.2014
- Identified trends with provider issues and rendered assistance to provider relation unit
- Received inbound and made outbound phone calls to assist provider with payment issues
- Responsible for creating and processing special project requests
- Processed pharmacy and dental claims, including: HFCA1500 and UB92 (outliers), Medical
- Transportation, Ambulance, Air transport
ENCOUNTERS ANALYST
ARIZONA PHYSICIANS IPA, UNITED HEALTHGROUP
05.1996 - 08.2006
- Processed encounter data according to AHCCCS guidelines and schedules
- Identified and analyzed system trends
- Determined payments per contract specifications and company guidelines
- Identified areas using collected data that assisted in providing additional training
UNIT COORDINATION
THE BRYMAN SCHOOL
Phoenix, AZ
01.1992 - 01.1993
SPECIALIST, Truck driver
UNITED STATES ARMY
01.1989 - 01.1991
- Duties included transporting water, food, gas and mail
- Guard duty for fort and weapons protection
Education
Health Administration
The Bryman School - Tempe
Tempe, AZSkills
- Strong Problem Solver
- Customer Satisfaction
- Medical Records Research
- Defect Tracking and Reporting
- Organization and Attention to Detail
- Client Meetings
- Test Program Development
- System Integration Testing
- Testing Analytics
- Providing Feedback
- Continuous Learning
- Team Support
- Understanding of Applicable Laws
Timeline
Associate Testing Analyst, TPL Admin., Check Trace
Finance Department
02.2016 - 08.2022
CLAIMS PROCESSOR
COVENANT CONSUMER
06.2014 - 06.2015
CLAIMS ANALYST III
HEALTH CHOICE ARIZONA
05.2008 - 08.2014
ENCOUNTERS ANALYST
ARIZONA PHYSICIANS IPA, UNITED HEALTHGROUP
05.1996 - 08.2006
UNIT COORDINATION
THE BRYMAN SCHOOL
01.1992 - 01.1993
SPECIALIST, Truck driver
UNITED STATES ARMY
01.1989 - 01.1991
CAREGIVER
DIRECT
RESEARCH ANALYST III, AUTHORIZATION ANALYST
Health Administration
The Bryman School - Tempe
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