ALETHEA BOYES
Boerne,TX
Summary
Accomplished Senior Claims Examiner with a proven track record at Well-Med Insurance, adept in complex claim adjudication and compliance regulation. Demonstrates exceptional detail orientation and effective communication, ensuring precision in healthcare claims processing and compliance audits. Spearheaded initiatives improving operational efficiency and employee training, reflecting a commitment to workforce growth and customer engagement.
Overview
16
16
years of professional experience
Work History
Senior Claims Examiner
Well-Med Insurance
San Antonio, Texas
10.2022 - Current
- Reviewed, analyzed, and researched complex healthcare claims to identify discrepancies and ensure accurate processing.
- Reviewed, processed, and identified medical claims.
- Applied appropriate processes and procedures to efficiently process claims.
- Resolved complex issues by manually adjusting pended escalated claims.
- Adjudicated complex medical provider-initiated claims with precision.
Compliance Specialist
Quick Med Claims
San Antonio, Texas
01.2018 - 10.2022
- Conducted regular audits of claims to ensure compliance with payor requirements and documented internal and external audit results for the Compliance team.
- Enforced compliance with HIPAA privacy regulations and conducted privacy audits to identify and mitigate risk areas.
- Collaborated with the Compliance team to create and deliver educational materials when there were new or changed regulations, requirements, or when targeted compliance training was needed.
- Conducted comprehensive audits on coding, billing, documentation, and reimbursement processes to ensure compliance.
- Updated department and company policies to align with changes in the regulatory environment.
- Provide F-10 certification for new Billing Specialists.
Practice Manager
Promptu Immediate Care
Boerne, Texas
06.2015 - 01.2018
- Implemented new procedures to enhance the environment for employees and patients.
- Interviewed, hired, and trained front desk staff, ensuring optimal performance and customer service.
- Monitored patient billing processes, ensuring accuracy and timely payments.
- Monitored and managed office and medical supply inventory to ensure operational efficiency.
- Conducted staff meetings to review updates and policies.
- Addressed patient concerns and issues to ensure a positive experience.
- Coordinated staffing needs across multiple facilities to ensure optimal workforce distribution.
- Coordinated Occupational Health referrals for specialty cases, ensuring timely and appropriate care.
Case Manager
Law Office of Susan Rice
Boerne, Texas
10.2008 - 06.2015
- Processed and prepared various court documents, petitions, promissory notes, and liens for legal review and signatures.
- Filed lawsuits electronically for the organization.
- Facilitated both verbal and electronic communication with clients and accounts to gather necessary documents and information to resolve issues.
- Facilitated client payment arrangements for account settlements.
- Organized all legal documents for attorney review, ensuring accuracy and completeness.
- Monitored past due accounts to facilitate effective debt collection.
- Prepared comprehensive status reports and detailed invoices for clients and accounts.
Education
Bachelor of Science - Health Administration/Long Term Care
University of Phoenix
Austin, TX01.2011
Skills
- Proficient in Customer Engagement
- Effective Communication
- Detail-Oriented Mindset
- Proficient Task Management
- Independent Work
- Dedicated to Ongoing Education
- Focus on Workforce Growth
Affiliations
- General Lines Agent, Life, Accident, Health Insurance License
References
Available upon request.
Timeline
Senior Claims Examiner
Well-Med Insurance
10.2022 - Current
Compliance Specialist
Quick Med Claims
01.2018 - 10.2022
Practice Manager
Promptu Immediate Care
06.2015 - 01.2018
Case Manager
Law Office of Susan Rice
10.2008 - 06.2015
Bachelor of Science - Health Administration/Long Term Care
University of Phoenix
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