Aubrey Wright
Saugus,CA
Summary
Experienced Medical Claims Adjudicator, Investigator, Grievance Coordinator, and Healthcare Prior Authorization. Comprehensive knowledge and understanding of the laws and guidelines concerning medical claims. Expertise in quickly analyzing documents and data to determine eligibility and course of action. Motivated employee with focus on strong results and attention to detail.
Overview
19
19
years of professional experience
Work History
Investigation/Provider Auditor/PPR Review/Appeal-Greivances
Blue Cross Blue Shield, Anthem
01.2011 - Current
- Receive, Investigate and answer inquiries and complaints related to Claims Adjudication/Appeals & Grievance and Membership
- Using Anthem systems, handle complex claims with "the" understanding of multiple products i.e
- HMO – PPO - COB, etc
- MEDICARE Crave Evaluate/investigate health insurance claims to ensure proper payment and coordination of benefits
- Process policies, procedures and regulations with healthcare terminology
- Conduct screening of customer grievance and appeals involving provisions of service and benefit coverage issues
- Generate correspondence to members and providers
- Verify enrollment status while making changes to system records for research and resolving claims
- Receive incoming calls and incoming correspondence involving routine inquires and multiple products regarding eligibility with claims
- Handle difficult inquiries from providers and patients with physical and/or psychological issues, conduct investigations as appropriate
- Determine appropriate resolution in compliance with DOI Administration
- Collects, researches, and validates bills and claims data against relevant guidelines
- Assists in preparation of statistical and financial analysis reports
- Requests medical records and additional documentation required
- Completes initial file set-up and tracks cases
- Processes and tracks all incoming reimbursement checks
- Develop work spreadsheets
- Managed over 50 customer calls per day.' and, "Increased claims revenue by 40%".
Prior Authorization Coordinator
Regal Medical Group
01.2008 - 01.2011
- Promote quality and cost effectiveness of medical care through strict adherence to all policies and procedures
- Completed extensive referral request process to include proper physicians and/or facility, diagnosis and procedure codes
- Reviewed claims, insurance and rejection orders to determine "the" type of authorization required
- Utilized multiple company database programs to request medical records adhering to HIPPA policy for case management
- Tracked and recorded communication between insurance carriers and facility representatives
- Maintained professional communications with provider offices and facilities.
Appeal & Grievance Coordinator
Health Net
01.2005 - 01.2008
- Provide A+ customer service to all internal & external customers
- Use of Anthem systems to evaluate and investigate health insurance claims to ensure proper payment and coordination of benefits
- Receive incoming calls involving routine inquires and multiple products regarding eligibility with claims through investigative skills
- Handle difficult inquiries (complaints) from providers and patients with physical and/or psychological issues
- Determine appropriate resolution in compliance with DOI Administration
- Successfully completed extensive customer service program including insurance benefits and navigation.
Education
CNA -
Kennedy King
Chicago, IL07.1995
HIGH SCHOOL -
Ulysses S. Grant Senior High School
Van Nuys, CA05.1993
Data Analytics -
CAL Bright College
San Francisco, CA03.2024
Skills
- Knowledgeable with laws regarding medical claims
- Research and Analysis
- Work with government claims processes
- Excellent oral and written communication
- Proficient with various coding software platforms
- Excellent in "a" team environment
- Familiar with "the" pre-adjudication process of filing medical claims
- Excellent Customer Service
Timeline
Investigation/Provider Auditor/PPR Review/Appeal-Greivances
Blue Cross Blue Shield, Anthem
01.2011 - Current
Prior Authorization Coordinator
Regal Medical Group
01.2008 - 01.2011
Appeal & Grievance Coordinator
Health Net
01.2005 - 01.2008
CNA -
Kennedy King
HIGH SCHOOL -
Ulysses S. Grant Senior High School
Data Analytics -
CAL Bright College