Arlene FrankWilliams
San Diego,CA
Summary
Ambitious, career-focused job seeker, anxious to obtain an entry-level Genetic Counselor position to help launch a career while achieving company goals. Dedicated Health Care professional with a history of meeting company goals utilizing consistent and organized practices. Skilled in working under pressure and adapting to new situations and challenges to best enhance the organizational brand. Excellent reputation for resolving problems and improving customer satisfaction. To seek and maintain a full-time position that offers professional challenges utilizing interpersonal skills, excellent time management, and problem-solving skills. Enthusiastic to contribute to team success through hard work, attention to detail, excellent organizational skills. Motivated to learn, grow and excel in this field.
Overview
26
26
years of professional experience
9
9
Certifications
3
3
Languages
Work History
CLAIMS DISPUTE ANALYST
Community Health Group
03.2021 - Current
- Use sound judgment, available resources to make well-informed decisions for appeal determination
- Analyze, research, investigate, resolve payment claims, apply reduction or denial within required time frames with high level of accuracy
- Keep up to date on industry information, system changes, network rules, compliance issues
- Adhere to department processes, procedures, goal expectations, contractual requirements established by regulatory agencies for case investigations
- Use critical thinking to break down problems, evaluate solutions, make decisions
- Excellent documentation skills
- Attention to details
- Identify, report patterns of incorrect system configuration that impacts payment process
- Participate in meetings, make recommendations for improvement.
CLAIMS ANALYST I
Community Health Group
06.2016 - 03.2021
- Collaborated with internal departments to get claims processed correctly
- Reviewed, analyzed suspicious and potentially fraudulent insurance claims
- Identified and reported patterns of incorrect system configuration that impacts payment
- Applied AWP pricing, ASP pricing, DME pricing, and payment reductions when applicable
- Coordinated benefits between Medicare, Medi-Cal, and other payers by analyzing primary payment remittance advice.
- Conducted thorough investigations into each claim, gathering relevant data and documentation to support decision-making processes
- Demonstrated high level of accuracy and attention to detail in reviewing claim documentation for approval or denial decisions
- Participated in ongoing training programs to stay current on industry developments, maintain strong understanding of relevant laws and regulations affecting claims process
- Viewed reports regularly to make sure processing was conducted efficiently
- Identified trends in claim patterns, providing actionable insights for process improvements and risk mitigation strategies
CLAIMS AUDITOR
Southern California Physicians Managed Care
09.2005 - 03.2016
- Monitored Prelags for timely processing to ensure compliance
- Reviewed Member Denial letters for timeliness and accuracy by verifying data in claims database against claim image
- Printed, sorted, submitted Letters and EOBs for mailing
- Performed daily audits of processed claims and provider disputes
- Logged productivity and accuracy of audits and submitted monthly reports by required due date
- Performed review of non-compliant health plan audits
- Developed and updated Member Denials policies and procedures
- Conducted day-to-day administrative tasks to maintain information files and process paperwork
- Verified insurance claims and determined fair amount for settlement
- Researched and completed special projects by required due date
- Trained new Claims Dispute Analyst.
- Collaborated with other departments as needed to ensure seamless communication during claims process, promoting effective teamwork across organization
- Provided valuable insights from audit findings to senior management for strategic decision-making purposes regarding operational improvements or risk mitigation efforts
- Reduced claims overpayment with comprehensive analysis of billing discrepancies and adherence to company policies
- Developed strong relationships with clients through transparent communication about their claim status and anticipated outcomes
- Maintained compliance with industry regulations by staying current on policy changes and updating procedures accordingly
- Provided high level of professionalism when speaking with customers or responding to emails to promote company's dedication to service
- Served as a subject matter expert within the Claims Auditor team, offering guidance when needed to support overall team effectiveness
CLAIMS EXAMINER
The Wellness Plan
06.1998 - 09.2005
- Resolved member and provider inquiries via Contact Service Form
- Released pending claims via Doc Flo
- Scanned claims related mail into Macess Entrendex System
- Effectively handled 20-30 calls daily, ensuring prompt resolution to callers' quandary or request and prompt customer satisfaction
- Conducted day-to-day administrative tasks to maintain information files and process paperwork
- Trained examiners to process Coordination of Benefits Claims
- Team member of Claims Cost Avoidance Project
- Accurately processed large volumes of medical claims daily.
- Served as mentor to junior examiners, sharing expertise, providing guidance on best practices within field of claims examination
- Assisted with development of training materials for new Claims Examiners, fostering supportive learning environment
- Handled sensitive information with discretion, ensuring confidentiality of personal and financial details for claimants throughout claims examination process
Education
Mini MBA - Business
Upskillist Online
Online 06.2023 - 06.2023
Some College (No Degree) - Business Administration: Marketing
University of Detroit Mercy
Detroit, MI 05.2003 - 05.2003
Diploma - Data Entry
Michigan Computer Institute
Detroit, MI 12.1989 - 12.1989
Skills
Fax Machine
Certification
Health Careers-2021
Accomplishments
- Used Microsoft Excel to develop inventory tracking spreadsheets
- Introduce Microsoft Excel for tracking daily productivity
- Achieved improved turnaround time by introducing due date tracker to streamline Claims Processing
- Achieved 99% by completing review of reports with accuracy and efficiency.
- Collaborated with team of Auditors and Consultants in the development of Claims Cost Avoidance Project
- Co-authored the Coordination of Benefits Policies and Procedures Manual
- Years of Service Recognition Awards
Affiliations
Bonita Valley Community Church
Timeline
Mini MBA - Business
Upskillist Online
06.2023 - 06.2023
CLAIMS DISPUTE ANALYST
Community Health Group
03.2021 - Current
CLAIMS ANALYST I
Community Health Group
06.2016 - 03.2021
CLAIMS AUDITOR
Southern California Physicians Managed Care
09.2005 - 03.2016
Some College (No Degree) - Business Administration: Marketing
University of Detroit Mercy
05.2003 - 05.2003
CLAIMS EXAMINER
The Wellness Plan
06.1998 - 09.2005
Diploma - Data Entry
Michigan Computer Institute
12.1989 - 12.1989