Au-Trina Myles
Avondale,LA
Summary
More than 20 years of experience in customer service and claims adjustments and processing, recognized strengths in first calls resolution, problem solving and troubleshooting, implementing proactive procedures and systems to avoid problems in the first place. First, call resolutions my main goal. Medicaid claims processor, adjustor, and call representative. Possess solid computer skills. Macros. Overpayments and refunds. Detail oriented, research skill excellent. Provider research, name, address, tin#. Provider first call resolution. Advanced knowledge using; Lotus 1-2-3, Microsoft Excel, WordPerfect, Microsoft Word, IDT main frame, EDDS Trace-y UNET, Linx, Avatar and PowerPoint. Ability to train, motivates, and supervises customer service employees. A team player, acknowledged as “Total Quality Customer Service Professional.”2012. Transfer to Claims Adjuster in 2007 for UHG. Main high claims productions. Exceeds in quality and productions goals. Receive many letters and emails about my Professional manner in handle customers, co-workers, and management. Trainer. Organized and detail-oriented Investigator dedicated to improving efficiency, productivity and profitability through continuous process improvement. Analytical thinker skilled at developing innovative solutions to complex problems. Claims Adjuster with deep experience in confidential litigation claims. Superbly positioned to investigate, evaluate and settle Outpatient, Inpatient and office claims. Excellent abilities to decipher fraudulent activities, analyze data, confer with legal counsel and communicate with online brokers to gain details for processing claims. Service-oriented Claims Adjuster skilled at applying creative approaches to solving complex problems. Adept at developing profitable and quality-focused processes. Motivated Member Services specializing in personal, property and casualty loss and damages. Negotiates peaceful resolutions of all claims with emphasis on fairness and thoroughness. Trustworthy and dependable.
Overview
15
15
years of professional experience
Work History
Claims Adjustor
- More than 20 years of experience in customer service and claims adjustments and processing, recognized strengths in first calls resolution, problem solving and troubleshooting, implementing proactive procedures and systems to avoid problems in the first place
- First, call resolutions my main goal
- Medicaid claims processor, adjustor, and call representative
- Possess solid computer skills
- Macros
- Overpayments and refunds
- Detail oriented, research skill excellent
- Provider research, name, address, tin#
- Provider first call resolution
- Advanced knowledge using; Lotus 1-2-3, Microsoft Excel, WordPerfect, Microsoft Word, IDT main frame, EDDS Trace-y UNET, Linx, Avatar and PowerPoint
- Ability to train, motivates, and supervises customer service employees
- A team player, acknowledged as “Total Quality Customer Service Professional.”2012
- Transfer to Claims Adjuster in 2007 for UHG
- Main high claims productions
- Exceeds in quality and productions goals
- Receive many letters and emails about my Professional manner in handle customers, co-workers, and management
- Trainer.
Benefit Analyst
CCMSI
- Responsible for 100% of phone calls
- Assist in all benefits questions for members and providers
- Send out all correspondences about the plan all updated and new insurance updates
- Issue ID cards
- Enter in New Enrollee’s
- Termed Enrollments
- Send out Certificate of Coverage
- Sort Mail
- Enter Mail
- Enter claims into Script care
- Setup Appeals
- Review claim status give information on how the claims paid and process to providers
- Assist members with finding in network providers
- Verify monthly active employee’s
- Running weekly letters
- Research bills from members to see if we have received the claims for the outstanding bills
- Received incoming faxes for eligibility, claim status, claims and checking information
- Create Spreadsheets for new projects
- Update W-9’s and update providers tax identification numbers and addresses for payments.
Claims Resolution Team
United Health Group
06.2021 - 06.2022
- Excellent oral and written communications skills
- Adjusting claims to ensure the correct payment first resolution
- Adjust for overpaid claims and underpaid claims
- Promptly and appropriately work spreadsheets large claims quality
- Analytical and interpretive skills
- Ability to work in a team environment
- Issuing overpayments adjusting claims for refunds
- Ability to meet or exceed Services Expectations
- Cross train to assist in many departments
- Assist in training new employee’s.
Customer Service Representative/Claims Specialist
Salt Lake County Medicaid Public Sector, UnitedHealth Group
01.2014 - 01.2021
- Process and adjust claims for Medicaid Mental Health providers
- Received incoming calls for claims status on claims submitted
- Answer question from co-workers or coordination of benefits, process facilities claims and per day-to-day operations
- Back up for my supervisor, for meeting and reports, assisting in areas when need
- Research and handle escalated issues via email and calls
- Overpayments and issue refunds
- Help with the writing of PnP’s created all new documents for new platform for policy and procedures
- Specialize in adjustments and overpayments.
Customer Service Representative/Claims Examiner
United Behavioral Healthcare
01.2007 - 01.2011
- Quickly and effectively, solve customer challenges
- Satisfy members, providers, and client with the quality of service received by responding courteously and accurately to all phone inquiries relating to eligibility issues, explanation of claims
- Went to specialized team within my first year
- Process Pacific Behavioral Health claims for payment
- Forward complex issue to the next level when necessary
- Quickly and effectively, solve customer challenges
- Satisfy members, providers, and client with the quality of service received by responding courteously and accurately to all phone inquiries relating to eligibility issues, explanation of claims
- Process Pacific Behavioral Health claims for payment
- Forward complex issue to the next level when necessary and appropriate.
Education
BA in Business Management - Business Management
Waldorf University
Iowa City, IA01.2019
AS in Business Administration -
Delgado Community College
01.2017
Skills
- Claims Investigation
- Highly motivated
- Claims Processing
- Advanced oral and written communication skills
Accomplishments
- Toastmasters International (United Health Group) 2016&2017 Dean List for having 3.8 GPA, Bachelors, Waldorf University
- In 1999 received the award for LSU Healthcare Employee of the Year Award
- AT&T check outstanding accomplishment for maintain a 100%quality for the month, September 2007.
- Receive a Certificate of Excellence for the month of January 2007 at United Behavioral health and many more the rest of the year.
- Receive many Certificates for 100% quality awards at United Behavioral health in the claims department as well.
- Receive Certificate of Recognition from Salt Lake County 2011
- Employee of the Month February 2012
- Employee of the month August 2012
References
Furnished Upon Request
Timeline
Claims Resolution Team
United Health Group
06.2021 - 06.2022
Customer Service Representative/Claims Specialist
Salt Lake County Medicaid Public Sector, UnitedHealth Group
01.2014 - 01.2021
Customer Service Representative/Claims Examiner
United Behavioral Healthcare
01.2007 - 01.2011
Claims Adjustor
Benefit Analyst
CCMSI
BA in Business Management - Business Management
Waldorf University
AS in Business Administration -
Delgado Community College
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