Amber Comuso
Langhorne,PA
Summary
Results-driven professional with a strong work ethic and adaptability, consistently delivering quality work in fast-paced environments. Known for exceptional interpersonal skills and effective communication, fostering teamwork to achieve company goals. Proven ability to master new skills quickly and contribute to a collaborative work culture. Committed to continuous learning and professional development to enhance service delivery.
Overview
22
22
years of professional experience
Work History
Appeals Analyst
Horizon Blue Cross Blue Shield of NJ
Hopewell, NJ
03.2023 - Current
- Analyzed and evaluated appeals to ensure compliance with applicable laws, regulations, policies and procedures.
- Gathered and documented evidence to support leadership appeals workgroup proceedings.
- Compiled data for appeals cases utilizing Microsoft Office Suite products.
- Participated in training sessions designed to keep abreast of new laws or regulations affecting the appeals process.
- Drafted correspondence responding to inquiries from internal and external stakeholders regarding the status of individual claims or general policy questions.
- Interpreted complex rules, regulations, policies and procedures related to appeals.
- Advised management on best practices for resolving difficult claims appeals.
- Developed strategies for efficient resolution of appeals cases.
- Conducted research on evidence submitted in support of appeals.
- Assisted patients with insurance questions by studying benefits.
- Actively monitored progress on pending appeal cases ensuring timely completion of tasks associated with each claim dispute resolution.
- Input claim information and payments into company database.
- Delivered exceptional customer service to clients by communicating information and actively listening to concerns.
- Reviewed policies to determine appropriate levels of coverage and assist with approval or denial decisions.
- Collaborated with leadership appeals workgroup on a week basis for upheld appeals.
- Discussed current cases and issues in claim committee meetings.
- Reviewed documents for accuracy and completeness prior to processing appeals.
- Coordinated with various departments when additional information was required for a successful resolution of an appeal.
- Created thorough summaries detailing outcomes of appeals.
- Maintained accurate records of all activities related to the appeals process.
- Reviewed patients' insurance coverage, deductibles, possible insurance carrier payments and remaining balances not covered under policies.
- Attended meetings with management staff concerning policy changes impacting the appeals process.
- Analyzed information gathered by investigations and reported findings and recommendations.
- Performed system analysis to detect and troubleshoot technical issues.
- Conducted testing of software and systems to ensure quality and reliability.
- Provided support and guidance to colleagues to maintain a collaborative work environment.
- Prioritized and organized tasks to efficiently accomplish service goals.
- Utilized various software and tools to streamline processes and optimize performance.
- Identified needs of customers promptly and efficiently.
- Initiated conversations with customers through exceptional interpersonal skills.
- Participated in ongoing education sessions consistently.
- Contributed innovative ideas and solutions to enhance team performance and outcomes.
- Updated and maintained databases with current information.
- Partnered with team members to fulfill project directives on schedule.
- Fostered collaboration within teams to enhance productivity.
- Exceeded customer satisfaction by finding creative solutions to problems.
- Completed day-to-day duties accurately and efficiently.
- Utilized document management system to organize company files, keeping up-to-date and easily accessible data.
- Collaborated with cross-functional teams on projects related to analytics initiatives.
- Formulated plans to resolve challenging issues.
- Maintained positive working relationship with fellow staff and management.
- Analyzed large datasets with statistical methods and software programs.
- Maintained accurate records of all data collected during analysis processes.
- Assisted with customer requests and answered questions to improve satisfaction.
- Maintained updated knowledge through continuing education and advanced training.
- Collaborated with teams from different departments to reach objectives.
- Provided excellent service and attention to customers through phone conversations.
- Applied considerable skill set for effective issue resolution.
- Applied analytical skills to address and solve problems promptly.
- Earned recognition for delivering excellent customer support.
- Promoted high customer satisfaction by resolving problems with knowledgeable and friendly service.
- Provided guidance to team members regarding tasks assigned to them.
- Communicated analytical findings with clarity and precision.
- Developed strong collaborative relationships across various departments.
- Engaged with team members to recognize and solve problems.
- Collaborated effectively with diverse coworkers to achieve objectives.
- Conducted comprehensive research and data analysis to support strategic planning and informed decision-making.
- Managed time effectively to ensure tasks were completed on schedule and deadlines were met.
- Demonstrated and distributed expertise acquired during a lengthy tenure at Horizon Blue Cross Blue Shield of New Jersey.
- Applied detailed data analysis to enable strategic decision-making.
- Engaged with colleagues to grasp and address shifting business requirements.
- Demonstrated strong problem-solving skills, resolving issues efficiently and effectively.
- Ensured timely completion of all assigned tasks within set deadlines.
- Partnered with audit team to achieve precise workflow execution.
- Worked with management to discuss external audit results and action plans.
- Ensured thorough coordination of audits by working closely with internal auditors.
- Demonstrated adaptability in a constantly changing environment.
- Employed root cause analysis techniques to resolve complex issues.
- Investigated root cause analysis for recurring problems identified by customers.
- Worked with cross-functional teams to achieve goals.
- Attended webinars to stay abreast of changes in the healthcare industry.
- Maintained up-to-date knowledge of current coding practices and changes in healthcare industry regulations.
- Developed a thorough understanding of CPT and HCPCS codes and modifiers used in the healthcare industry.
- Ensured compliance with all federal, state and local laws related to healthcare industry regulations.
- Engaged in continuing education to develop analytical abilities.
- Managed caseloads effectively, ensuring timely documentation and reporting.
Research Analyst
Horizon Blue Cross Blue Shield of NJ
Mt. Laurel, NJ
05.2004 - Current
- Verified information to ensure accurate reporting.
- Developed standard templates for commonly used communication forms.
- Compiled complete and precise information through extensive claims research.
- Provided prompt reporting by adhering to deadlines with organized research and polished delivery.
- Researched and compiled information for reports.
- Developed creative solutions for streamlining processes within the department to increase efficiency.
- Responded promptly to requests from customers for additional information on products or services offered by the company.
- Resolved discrepancies between paper-based files and electronic databases.
- Ensured compliance with applicable laws regarding privacy requirements when handling sensitive data.
- Assisted with preparing responses to inquiries from customers or other external parties.
- Participated in meetings discussing new policies related to managing customer relations through effective communication strategies.
- Proofread, formatted and prepared internal documents such as memos, letters and reports for distribution.
- Gathered data to formulate appropriate replies for information requests.
- Researched customer accounts using available resources when additional information was needed for a response letter.
- Collaborated with other departments within the organization on projects involving coordination of written communications.
- Simplified terms to enhance understanding for general audience.
- Answered phone calls and provided assistance with general inquiries related to correspondence matters.
- Read user manuals and administrative materials to determine necessary actions for issues.
- Reviewed written correspondence, correcting grammatical and spelling errors.
- Conducted thorough reviews of correspondence for precision.
- Resolved issues related to products and services raised by customers.
- Worked with cross-functional teams to achieve goals.
- Prioritized and organized tasks to efficiently accomplish service goals.
- Recognized by management on multiple occasions for providing exceptional customer service.
- Worked successfully with diverse group of coworkers to accomplish goals and address issues related to our products and services.
- Applied specialized technical knowledge for effective problem-solving in complex situations.
- Utilized a variety of tools such as Excel spreadsheets and databases for effective data manipulation and analysis.
- Contributed innovative ideas and solutions to enhance team performance and outcomes.
- Worked effectively in team environments to make the workplace more productive.
- Collaborated closely with team members to achieve project objectives and meet deadlines.
- Exceeded customer satisfaction by finding creative solutions to problems.
Claims Specialist
Horizon Blue Cross Blue Shield of NJ
Mt. Laurel, NJ
12.2002 - Current
- Verified claim data correctness in preparation for processing.
- Followed up on pending claims and resolved issues delaying processing.
- Analyzed differences between submitted papers and actual logs to identify gaps.
- Identified and flagged suspicious claims for further investigation.
- Checked documentation for appropriate coding, catching errors and making revisions.
- Evaluated historical data to verify service benefit eligibility.
- Analyzed patterns in claim denials stemming from provider coding issues.
- Examined claims, records and procedures to grant approval of coverage.
- Performed additional duties as requested by management team.
- Enhanced job knowledge through engaging in educational programs.
- Contributed to creating and applying process enhancements.
- Collaborated with fellow team members to manage large volume of claims.
- Analyzed contracts and claim systems to apply appropriate benefit amounts.
- Reviewed and processed incoming insurance claims to ensure accuracy and completeness.
- Mentored newly hired team members in proper claims procedure.
- Updated claim files and documented actions taken in a clear and concise manner.
- Processed a high volume of incoming claims in accordance with established policies and procedures.
- Monitored updates in insurance regulations and policies impacting claims processing.
- Applied knowledge of coding systems such as CPT-4 and HCPCS codes for proper reimbursement.
- Utilized claims processing software to streamline workflow and increase efficiency.
- Delivered detailed explanations for claims during external audits.
- Protected sensitive policyholder data per HIPAA guidelines.
- Structured information with various digital tools such as spreadsheets, databases, and word processors.
- Analyzed and evaluated claim forms, medical reports, bills, and other documents to ensure accuracy of data.
- Executed comprehensive audits on claims files to uphold company policies.
- Collaborated closely with team members to achieve project objectives and meet deadlines.
- Worked with cross-functional teams to achieve goals.
Education
High School Diploma -
Northern Burlington County Regional High School
Columbus06-1999
Some College (No Degree) - Business Administration
Rowan College At Burlington County
Pemberton, NJSkills
- Regulatory compliance
- Data analysis
- Claims processing
- Evidence gathering
- Policy interpretation
- Customer service
- Appeals resolution
- Team collaboration
- Problem solving
- Time management
- Communication skills
- Research skills
- Process improvement
- Critical thinking
- Claims investigation
- Decision-making skills
- Case reporting
- Effective communication
- Attention to detail
- Conflict resolution
- Investigation techniques
- File and record management
- Teamwork skills
- Problem-solving abilities
- Adaptability and flexibility
- Microsoft Office
- Analytical and critical thinking
- Training & Development
- Dependable and responsible
- Analytical thinking
- Troubleshooting
Languages
English
Professional
Interests
- Crocheting or anything crafty
- Volunteering at local animal shelter
- Walking
- Continued education
References
References available upon request.
Timeline
Appeals Analyst
Horizon Blue Cross Blue Shield of NJ
03.2023 - Current
Research Analyst
Horizon Blue Cross Blue Shield of NJ
05.2004 - Current
Claims Specialist
Horizon Blue Cross Blue Shield of NJ
12.2002 - Current
High School Diploma -
Northern Burlington County Regional High School
Some College (No Degree) - Business Administration
Rowan College At Burlington County
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