Amber Putnam

• Enhanced team collaboration with effective communication and sharing of best practices in claims auditing.
• Fostered a positive working environment within the claims audit team through open communication channels, constructive feedback mechanisms, and promoting a culture of continuous learning.
• Contributed to continuous improvement initiatives within the organization by actively participating in brainstorming sessions focused on optimizing processes within the claims department.
• Assisted in the development of internal audit guidelines and best practices documentation, leading to increased consistency and quality across the department''s work output.
• Provided exceptional customer service to clients during the audit process, addressing concerns and delivering timely updates on claim status.
• Researched claims and incident information to deliver solutions and resolve problems.
• Efficiently managed multiple concurrent audits while maintaining attention to detail and accuracy in reporting findings.
• Streamlined audit procedures for faster turnaround times, enabling quicker claim resolution.

• This is my most recent and current position
• Quality Assurance Specialist supports the team and business by serving as a quality champion through measuring and monitoring the quality and effectiveness of work processes in claim processing that impact customer satisfaction, medical cost management, and operational efficiency
• Consult and/or work cross functionally to influence and promote change to continually deliver quality service to our internal and external customers
• Will be a key resource in auditing/mentoring trainee processors
• Mentor and work with newer staff to help them become successful claim processors
• Mentoring done face-to- face or with a telework employee
• Good communication skills and able to explain claim policies and procedures to a new staff member
• Pleasant attitude and patience to work with new team members
• Main focus of my position as a Quality Assurance Specialist is to conduct and support customer third party audits
• Audit types include stratified, random, financial, and pre-implementation/plan set up testing
• Third party audits are presented via WebEx and Microsoft Team meetings with external audit firms
• Conduct investigations for external audit firm inquiries or questions regarding Plan Sponsor benefits, claims, policies, and other types of information
• Experience Processing Claims on ACAS
• ACAS claim processing experience on Traditional products
• Meet and/or exceed key performance indicators, including metrics and competencies/behaviors
• Proven track-record of consistent and reliable attendance:
• Present a positive, professional image of the company at all times
• Work collaboratively, ability to communicate effectively, ability to identify risks early, strong organizational skills and solid leadership skills
• Adapts communications to meet the needs of the intended audience
• Engages and connects with both remote and office-based staff
• Demonstrates the ability to be flexible and creative in a fast paced, constantly changing environment
• This position supports Local Market East Region claim processing teams and report to a Quality supervisor.

• Achieve superior claim and member service performance through an integrated process of operational, quality, medical cost, and resource management meeting and/or exceeding member, plan sponsor, and provider expectations
• Reviews and adjudicates claims in accordance with claim processing guidelines Fundamental Components & Physical Requirements include but are not limited to:
• Analyzes and approves claims
• Completes work with a limited degree of supervision
• Assesses claims up to given Authority limit- lower $ value claims and advice from designated Specialists
• (Senior Claim Benefits Specialist and Medical Claim Benefits Specialist colleagues)
• Proofs claim or referral submission to determine, review, or apply appropriate guidelines, coding, member identification processes, provider selection processes, claim coding, including procedure, diagnosis, and pre- coding requirements
• Investigate claims for possible abuse and fraud
• Conducts outreach activities including but not limited to email, member calls, provider calls as part of the claims adjudication process
• In accordance with prescribed operational guidelines, manages claims on desk, route/queues, and all systems within specified turn-around-time parameters
• Utilizes all applicable system functions available ensuring accurate and timely claim processing service (i.e., use of all documented resources)
• Escalate unresolved claims complaints and high costs claims to the claim's supervisor for guidance
• Continually work to improve best practices procedures and standards
• Ensures compliance with requirements of regional compliance authority/industry regulator
• Adheres to international privacy policies, practices, and procedures
• Exhibits the following Employee Behaviors
• Additional responsibility:

Handling Claim Projects for Performance Guarantee Accounts.

• Coordinated and planned investigations of claims to confirm compensability and coverage.
• Checked documentation for appropriate coding, catching errors and making revisions.
• Built rapport and trust with injured insureds through effective customer service techniques which involved fair and prompt processing of claims.
• Collaborated with fellow team members to manage large volume of claims.
• Processed claims according to established quality and production standards and made corrections and adjustments to solve problems.
• Reviewed history records to determine benefit eligibility for services.
• Verified claim data correctness in preparation for processing.
• Retained strong medical terminology understanding in effort to better comprehend procedures.
• Organized information by using spreadsheets, databases or word processing applications.

• Obtained patient vital signs and reported results to staff nurse or physician to identify changes from prior measurements.
• Completed frequent cleaning and sanitizing to maintain healthy environment for patients.
• Delivered outstanding patient care based on physical, psychological, educational and related criteria.
• Kept instruments and equipment clean and sanitized.
• Collected biological specimens and packaged for laboratory transport to complete diagnostic tests.
• Responded to bell or light signal calls to assist patients with needs.
• Examined and treated patient lacerations, contusions and physical symptoms and referred patients to other medical professionals.
• Supported healthy patient skin with bedside baths, wound care and integrity checks.
• Monitored, measured and documented patients' vital signs in EMR system.
• Identified and reported observations and clinical symptoms to appropriate healthcare professionals, driving timely intervention.
• Transported patients to other areas of hospital in wheelchairs and gurneys for tests, treatments and therapies.
• Documented patient intake and dietary requirements and aided with feeding and monitoring.
• Promoted patient satisfaction by assisting with bathing, dressing and exercising.
• Looked for physical, emotional and symptomatic changes in patient condition and obtained necessary care for medical concerns.
• Responded to patient emergencies and physically stressful situations to restore calm or administer treatments.
• Notified senior staff of patient emergencies to optimize outcomes.