Amy Edgemon
Indianapolis,IN
Summary
Results-driven claims professional with a long track record in benefit claim processing, recovery case review, and reinsurance filing. Strengths include documentation review, error resolution, and client communication. Focused on accurate, compliant claims decisions and efficient issue resolution.
Overview
1
1
Certification
25
25
years of professional experience
Work History
Predetermination Specialist
American Health Data Institute
Indianapolis, IN
06.2017 - Current
- - Assessed patient cases for eligibility related to healthcare services and benefits.
- - Coordinated communication with healthcare providers to clarify patient information and requirements, ensuring timely resolution of inquiries.
- - Partnered with analysts and clinicians to manage data clarification requests and maintain accuracy.
- - Supported policy adherence by contributing to training initiatives and compliance efforts, enhancing team understanding of regulations.
- - Created training materials for new hires on company procedures and policies, facilitating smoother onboarding and integration.
Service Processor
Key Benefit Administrators
Indianapolis, Indiana
06.2012 - 07.2017
- Managed benefit claim processing, ensuring adherence to policy and compliance requirements.
- Audited claim documentation, verifying accuracy and completeness to maintain processing integrity.
- Resolved processing errors by reprocessing claims for accurate payment and initiating refund requests for overpayments.
Recovery Specialist
Key Benefit Administrators
Indianapolis, Indiana
04.2006 - 05.2012
- Managed recovery case reviews for Key Benefit Administrators, ensuring accurate assessment and resolution of medical claims.
- Coordinated outreach to members, providers, and carriers for effective communication of recovery requests, enhancing stakeholder engagement.
- Prepared and filed claims with reinsurance carriers for high-value claims, securing timely client refunds.
- Prepared and filed claims with reinsurance carriers for claims above aggregate threshold to secure client refunds.
Claims Specialist
Key Benefit Administrators
Indianapolis, IN
10.2001 - 04.2012
- Completed claim outcomes through thorough documentation review, benefit calculation, and settlement determination.
- Compliance was maintained through careful review and processing of insurance claims.
- Coverage questions and claim disputes were resolved through plan provision review.
- Enhanced client understanding through timely updates on claim status and requirements.
- Entered accurate claim records into administration systems to ensure compliance and efficiency.
Education
Some College (No Degree) - Nursing
Ball State University
Muncie, INSkills
- Predetermination review
- Benefit eligibility
- Claims adjudication
- Policy interpretation
- Claims systems
- Healthcare administration
Certification
- Licensed to process claims in New York
Timeline
Predetermination Specialist
American Health Data Institute
06.2017 - Current
Service Processor
Key Benefit Administrators
06.2012 - 07.2017
Recovery Specialist
Key Benefit Administrators
04.2006 - 05.2012
Claims Specialist
Key Benefit Administrators
10.2001 - 04.2012
Some College (No Degree) - Nursing
Ball State University