Years in Medical & Behavioral Health Insurance Claims
ANGELIA BURTON
Killeen,TX
Summary
Skilled Medical Claims Examiner possessing extensive knowledge of medical insurance policies and procedures. Manages claims processing and adjudication with strong attention to detail while continuously providing excellent customer service. Great verbal and written communicator with strong background cultivating positive relationships and exceeding goals.
Overview
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9
Work History
Claims Examiner
Rose International, Inc. for Baylor S&WH
Temple, TX
01.2023 - Current
- Analyze and resolves unpaid claims issues; updates status of claims and provides explanation of denied, pending, and rejected claims
- Performs claim adjustments to re-issue and/or recoup proper payment amounts; reviews, researches and coordinates complaints, grievances, appeals and reconsiderations
- Interprets both Coordination of Benefits (COB) and Explanation of Benefits (EOB)
- Works within multiple client systems, programs and guidelines; verifies member eligibility and benefits, authorization requirements and other record information
- Regularly assists with special claims related projects assigned by leadership team; maintains confidentiality of member information in compliance with HIPAA and meets productivity and accuracy standards
- Maintained knowledge of benefits claim processing, claims principles, medical terminology, and procedures and HIPAA regulations.
- Verified patient insurance coverage and benefits for medical claims.
- Paid or denied medical claims based upon established claims processing criteria.
- Reviewed provider coding information to report services and verify correctness.
Amazon HR Assistant
Aston Carter for Amazon
Austin, TX
01.2022 - 05.2022
- Acted as point of contact for employee concerns about Amazon's Covid attendance policy
- Coordinated, monitored, assigned and documented employee Covid ELR (Emergency Leave Request)
- Regularly updated HR database to reflect employee information, changes in attendance policy, and other details
- Handled employee conflicts efficiently while following all company procedures
- Documented human resources records and maintained confidentiality of sensitive personal information
Claims Liaison
Cenpatico/Superior Health Plan
Austin, TX
01.2016 - 05.2020
- Confirmed and reviewed member behavioral health eligibility and benefits; specialized in processing behavioral health and medical claims received by paper or electronically
- Followed up with providers to resolve outstanding complex claim issues
- Reviewed claim documentation for appropriate coding caught errors and made necessary revisions
- Evaluated pending claims; identified and resolved problems that blocked auto-adjudication
- Served as a Subject Matter Expert and conducted training as required
Provider Assist Claims Representative
Accenture/TMHP
Austin, TX
07.2014 - 12.2015
- Educated TX Medicaid Providers with Texas Medicaid policies, procedures, eligibility and benefits related to claims processing
- Educated providers on various uses of NPI, TPI and TIN
- Provided behavioral health claims support: reviewed, researched, and investigated Amysis, CMS and TruCare
- Researched and analyzed complex claims to determine next steps and possible outcomes
- Generated, posted and attached information to claim files
- Maintained strong knowledge of basic medical terminology to better understand services and procedures
- Coordinated with contracting department to resolve payer issues
- Cross-trained and provided backup for customer service managers
Education
High School Diploma -
Ponchatoula High School
Tangipahoa Parish, Louisiana05.1996
Skills
- Typing and Computer Navigational Skills with Attention to Details
- Third Party Liability related to Claims Processing and Payment
- Strong PC knowledge
- Microsoft Office, One Drive, Word, Outlook, Excel, OneNote, Teams, PowerPoint, WebX
- Knowledge of UB-04, CMS 1500, EOB, COB, CPT, HCPCS, Rev Codes, ICD9, ICD10, Modifiers, etc
- Claims Processing, Claims Evaluation, Claims Investigation, Claims Adjustment
- Critical Thinking
- Denied Claims Identification
- Team Training
- Benefits Review
- Fraudulent Claims Investigation
- Insurance Policy Coverage Knowledge
- Claim Form Analysis
- Liability Determination
- Decision-Making
Timeline
Claims Examiner
Rose International, Inc. for Baylor S&WH
01.2023 - Current
Amazon HR Assistant
Aston Carter for Amazon
01.2022 - 05.2022
Claims Liaison
Cenpatico/Superior Health Plan
01.2016 - 05.2020
Provider Assist Claims Representative
Accenture/TMHP
07.2014 - 12.2015
High School Diploma -
Ponchatoula High School