Angela Smith
Crowley,TX
Summary
Claims Manager with extensive 25-year background in Managed Care, proficient in managing intricate claims and maintaining compliance with regulations. History of driving team success and refining operational workflows for enhanced performance. Interested in applying skills within a dynamic organization that supports career advancement.
Overview
28
28
years of professional experience
1
1
Certification
Work History
Claims Manager
Cook Children’s Health Systems
Fort Worth, TX
05.2023 - Current
- Enhanced customer satisfaction through timely and accurate claims resolutions.
- Implemented quality assurance measures, monitoring staff performance and delivering constructive feedback.
- Developed training materials to standardize claims handling across department.
- Collaborated with departments to optimize organizational effectiveness in addressing client needs.
- Documented and communicated claims information, supporting accurate processing outcomes.
- Determined appropriate courses of action for efficient claims processing.
Claims Operations Supervisor
Cook Children's Health Plan
Fort Worth, Texas
05.2021 - 05.2023
- Plan, organize, and supervise complex projects.
- Plan, assign, train, and direct work of staff. Manage inventory, work with management to mitigate high-priority issues, and implement proper division of responsibilities daily.
- Develop training and SOP guidelines that communicate clear, concise directions to employees.
- Release high-dollar claims.
- Maintain knowledge of benefits claim processing, claims principles, medical terminology and procedures, and HIPAA regulations.
- Interview and train new employees for production positions.
- Resolve State Complaints and Appeals using problem-solving skills.
- Identify system workflow requirements to enhance team efficiency.
- Managed a large volume of medical claims daily.
- State complaints.
- Internal emails escalation/complaints.
- State reports
- Departmental reports for quality and production guidelines.
- PTO requests.
- Research escalated issues to determine if a ticket is required.
Claims Team Leader
Cook Children’s Health Systems
Fort Worth, TX
03.2018 - 05.2021
- Managed inventory and collaborated with management to address high-priority issues daily.
- Developed training materials and SOP guidelines to provide clear instructions to employees.
- Processed high-value claims efficiently to minimize financial exposure.
- Maintained expertise in benefits claim processing, medical terminology, and HIPAA regulations.
- Conducted interviews and trained new employees for production roles.
- Resolved state complaints and appeals through effective problem-solving strategies.
- Identified system workflow requirements to optimize team productivity.
Claims Examiner
Cook Children's Health Plan
Fort Worth, TX
02.2016 - 03.2018
- Oversaw inventory management, enhancing operational efficiency across departments.
- Monitored claims adjudication compliance with relevant state regulations.
- Reviewed high-dollar claims and prepared documentation for audit evaluation.
- Supported staff by resolving claim inquiries and assisting with special projects.
Patient Account Representative
Cook Children's Physician Network
Fort Worth, TX
03.2011 - 02.2016
- Clarified insurance benefits and cost share requirements for both insured and uninsured patients.
- Assessed CPT and ICD codes necessary for accurate reimbursement and prior authorization.
- Evaluated potential financial liabilities for patients receiving specific services.
- Managed audits, corrections, and releases of claims on hold due to pending provider dictation.
- Maintained expertise in complex benefit levels, limitations, and coverage issues.
- Interfaced with patient financial services and billing staff to address customer billing inquiries.
Customer Service Representative
Alpine Access (Remote)
Denver, CO
08.2007 - 03.2011
- Assisted clients with understanding account terms and conditions, while providing status updates.
- Maintained client satisfaction by promoting timely follow-up on payments and resolving issues.
Claims Re-pricer Level 4
PHCS
New Orleans, LA
08.2002 - 01.2006
- Reviewed bill types, DRG codes, HCPCS, and ICD-9 to determine pricing applications for hospital claims.
- Executed manual calculations for both hospital and professional claims submitted electronically and via mail.
- Communicated with providers and clients regarding initial and duplicate submissions as well as corrected claims.
- Managed appeals process through effective written and oral communication with stakeholders.
Adjustments and Special Projects Analyst
The Oath of Louisiana
New Orleans, LA
11.2001 - 05.2002
- Researched/adjusted claims that were denied or unpaid according to the provider contract.
- Verified provider contracts were loaded correctly to ensure proper payment of all types of claims submitted.
SmartPlan 65 Claims Analyst
The Oath of Louisiana
New Orleans, LA
10.1999 - 11.2001
- Processed electronic/paper submission of Medicare and Commercial professional/hospital claims also verified vendor addresses and managed pend reports.
Commercial Customer Service Representative
The Oath of Louisiana
New Orleans, LA
01.1998 - 10.1999
- Aided members and providers by clarifying benefits and eligibility for claims.
- Processed claims adjustments to improve efficiency in claims management.
- Distributed provider directories and claim forms to support member needs.
- Provided copies of Explanation of Benefits as requested, ensuring transparency in claims handling.
Education
Medical Billing And Coding
Remington College
Fort Worth, TX04.2011
Nursing
Delgado Community College
New Orleans, LA04.1993
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John F. Kennedy High School
New Orleans, LA05.1991
Skills
- CPT/HCPCS coding and DRG management
- Claims adjudication and adjustments
- NCQA accreditation
- Organizational and analytical skills
- Communication and time management
- Standard operating procedure development
- Optum CES expertise
- Microsoft Office applications
- Tapestry proficiency
- AS400 knowledge
- Medi-tech experience
- Athena familiarity
- 3M core grouping
Certification
Certified Coding Specialist - 2011
Timeline
Claims Manager
Cook Children’s Health Systems
05.2023 - Current
Claims Operations Supervisor
Cook Children's Health Plan
05.2021 - 05.2023
Claims Team Leader
Cook Children’s Health Systems
03.2018 - 05.2021
Claims Examiner
Cook Children's Health Plan
02.2016 - 03.2018
Patient Account Representative
Cook Children's Physician Network
03.2011 - 02.2016
Customer Service Representative
Alpine Access (Remote)
08.2007 - 03.2011
Claims Re-pricer Level 4
PHCS
08.2002 - 01.2006
Adjustments and Special Projects Analyst
The Oath of Louisiana
11.2001 - 05.2002
SmartPlan 65 Claims Analyst
The Oath of Louisiana
10.1999 - 11.2001
Commercial Customer Service Representative
The Oath of Louisiana
01.1998 - 10.1999
Medical Billing And Coding
Remington College
Nursing
Delgado Community College
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John F. Kennedy High School