Ashley Woodcock
Rotonda West,FL
Summary
Detail-oriented professional driven to resolve claims fairly while representing interests of employer. Conducts thorough and informed investigations, precisely evaluates losses and negotiates settlements that satisfy diverse parties. Builds and maintains professional and productive relationships and works to understand potentially conflicting points of view.
Overview
21
21
years of professional experience
Work History
Claims Specialist II D&V
Randstad/Aflac
Tampa , FL
05.2024 - 07.2024
- Processed payments for valid claims according to established procedures.
- Performed periodic audits of closed files to ensure accuracy of documentation and compliance with regulations.
- Collaborated with other departments within the organization to resolve issues related to claims processing.
- Reviewed and analyzed insurance claims to determine validity, completeness, accuracy, and eligibility for payment.
- Resolved claims by approving or denying documentation, calculating benefits due and determining compensation settlement.
- Maintained up-to-date knowledge of insurance laws and regulations.
- Reviewed and processed insurance claims to ensure accurate and timely resolution.
- Analyzed and interpreted policy terms to apply appropriate coverage.
- Monitored reserve accuracy and made necessary adjustments.
- Calculated and authorized payment of claims within specified limits.
- Collaborated with fellow team members to manage large volume of claims.
Medical Claims Examiner
Conduent
Lexington, KY
11.2010 - 06.2024
- Stayed current on HIPAA regulations, benefits claims processing, medical terminology, and other procedures.
- Accurately processed large volume of medical claims every shift.
- Evaluated pending claims to identify and resolve problems blocking auto-adjudication.
- Tracked differences between plans to correctly determine eligibility and assess claims against benefits and data entry requirements.
- Based payment or denials of medical claims upon well-established criteria for claims processing.
- Processed claims for payment or forwarded to appropriate personnel for further investigation
- Reviewed Claims for OHI (Other Health Insurance)
- Processed claims using COB (Coordination of Benefit)
- Ensured HIPAA compliance by maintaining strict confidentiality of patient information.
- Researched medical records to identify additional information needed for processing claims.
- Assessed coding accuracy, using ICD-10 codes, CPT codes, HCPCS codes, and modifiers.
- Reviewed and processed medical claims for accuracy and completeness according to established guidelines.
- Validated that all necessary documentation was included with each claim submission.
- Reviewed administrative guidelines whenever questions arose during processing of claims.
Medical Claims Examiner
Molina Healthcare
New Port , CA
05.2022 - 12.2023
- Reviewed and processed medical claims for accuracy and completeness according to established guidelines.
- Participated in process improvement initiatives aimed at streamlining workflow processes.
- Determined the appropriate payment amount based on contractual agreements with providers.
- Researched medical records to identify additional information needed for processing claims.
- Ensured HIPAA compliance by maintaining strict confidentiality of patient information.
- Investigated discrepancies in claims data, reconciled errors, and corrected inaccuracies as needed.
- Assessed coding accuracy, using ICD-10 codes, CPT codes, HCPCS codes, and modifiers.
- Maintained updated knowledge of changes in healthcare regulations impacting claims processing.
- Analyzed provider contracts to ensure proper reimbursement levels were achieved.
- Based payment or denials of medical claims upon well-established criteria for claims processing.
- Stayed current on HIPAA regulations, benefits claims processing, medical terminology and other procedures.
- Used contract notes and processing manual to correctly apply group-specific classifications to claims.
- Accurately processed large volume of medical claims every shift.
Customer Service Representative
Kentucky Utilities
Lexington, KY
09.2008 - 11.2010
- Assisted customers in making payments on accounts and setting up payment plans.
- Upheld strict quality control policies and procedures during customer interactions.
- Informed customers about billing procedures, processed payments and provided payment option setup assistance.
- Set up and activated customer accounts.
Help Desk Support Specialist
Kentucky Transportation Cabinet
Frankfort, KY
08.2003 - 09.2008
- Supported employees with advanced troubleshooting on helpdesk tickets.
- Oversaw and supported County Clerks environments for on-site and virtual locations.
Education
GED -
Frankfort High School
Frankfort, KY05.2001
Some College (No Degree) - Information Technology
Southcentral Kentucky Community And Technical College
Lexington, KYSkills
- Medical terminology
- Meticulous recordkeeping
- Insurance claims management
- Records security practices
- Claim validity determination
- Compliance and Regulations
- Multitasking
- Strong Analytical Skills
- Microsoft Office
- Claims Processing
- Insurance knowledge
- Teamwork and Collaboration
- Understanding of medical terms
- Medical Terminology
- Medicaid knowledge
- Problem-Solving
- Self Motivation
- Organizing and Prioritizing Work
- 10-Key Touch
Timeline
Claims Specialist II D&V
Randstad/Aflac
05.2024 - 07.2024
Medical Claims Examiner
Molina Healthcare
05.2022 - 12.2023
Medical Claims Examiner
Conduent
11.2010 - 06.2024
Customer Service Representative
Kentucky Utilities
09.2008 - 11.2010
Help Desk Support Specialist
Kentucky Transportation Cabinet
08.2003 - 09.2008
GED -
Frankfort High School
Some College (No Degree) - Information Technology
Southcentral Kentucky Community And Technical College
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