Summary
Overview
Work History
Education
Skills
Software System Expertise
Timeline
Generic

Barbara Williams

Humble,TX

Summary

Results-focused and highly detail-oriented Claims Processing Specialist with 5+ years of experience adjudicating, reviewing, and auditing medical, dental, and pharmacy claims in high-volume production environments. Demonstrated success in meeting strict turnaround times (TAT) and client performance guarantees, while maintaining accuracy rates above 98%. Proficient in CMS-1500, UB-04, ICD-10, CPT, HCPCS, and resolving claim denials through thorough research and root cause analysis. Experienced with claims adjudication platforms, including Facets, EZ-CAP, Macess, and ServiceNow. Fully compliant with HIPAA, CMS guidelines, and internal auditing standards.

Overview

14
14
years of professional experience

Work History

Healthcare Claims Processing Specialist

HCA Healthcare Hospital
Houston, TX
03.2020 - Current
  • Accurately adjudicate over 22,000 medical and pharmacy claims annually using Facets and EDI 837 files.
  • Maintain a 99.1% accuracy rate and exceeded daily productivity goals by 15% for 18 consecutive months.
  • Review CMS-1500 and UB-04 forms, ensuring claim compliance with state and federal regulations.
  • Reduce denied claims by 24% through issue resolution, policy application, and provider outreach.
  • Complete claim integrity reviews in accordance with CVS Health’s production standards.
  • Perform outbound verification calls to providers and members to resolve claim discrepancies.
  • Collaborate with the Utilization Management and Eligibility departments to improve accuracy and reduce backlog by 33%.
  • Participate in quality audits and corrected 100% of flagged errors within 24 hours.
  • Train new processors on claims entry workflows, system use, and HIPAA compliance.
  • Successfully meet company’s turnaround time benchmarks for claim resolution.

Medical Claims Adjudicator

HCA Healthcare Hospital
Houston , TX
01.2017 - 02.2020
  • Processed an average of 95+ claims daily, consistently meeting 99% accuracy targets.
  • Reviewed inpatient, outpatient, and professional claims using ICD-10, CPT, and HCPCS codes.
  • Reduced claim cycle times from 7 days to 3.5 days by streamlining intake and routing.
  • Handled claim adjustments for incorrect payments and submitted over 700 correction requests in 12 months.
  • Documented appeals and grievances related to denied claims, supporting appeal outcomes with evidence.
  • Used QCare, ServiceNow, and Macess to manage and track adjudication workflows.
  • Participated in claims audits covering over 1,500 files with zero compliance issues.
  • Escalated systemic processing errors to supervisors and supported resolution initiatives.
  • Collaborated with the pharmacy team to verify prior authorizations on related medication claims.
  • Created team documentation that improved new hire claim accuracy by 18%.

Pharmacy Claims Associate

Walgreens
Houston , TX
08.2014 - 12.2016
  • Adjudicated over 18,000 pharmacy claims annually using EDI 835, maintaining 99.2% accuracy.
  • Resolved claim edits and denials involving drug formularies and benefit restrictions.
  • Verified plan eligibility, coverage levels, and coordination of benefits (COB) for members.
  • Reduced repeat rejections by 22% through provider education and audit reviews.
  • Performed weekly audits of pharmacy claims batches, identifying discrepancies with drug codes.
  • Used Cognizant TriZetto to enter and process claims with accurate coding and payment info.
  • Partnered with PBM and customer service teams to correct prior authorization issues in real-time.
  • Investigated potential fraud, waste, and abuse (FWA) trends in high-volume pharmacy submissions.
  • Documented claim histories and case notes using Salesforce and Outlook.
  • Reduced provider escalation calls by 15% through proactive resolution and follow-up.

Claims & Eligibility Coordinator

Texas Children Hospital
Houston , TX
01.2012 - 08.2014
  • Verified benefits and authorizations for over 500 patients weekly across multiple insurance plans.
  • Processed CMS-1500 and UB-04 claims using ICD-10 and CPT coding standards.
  • Coordinated with care management to validate medical necessity and support timely claims processing.
  • Investigated claim delays and resolved 95% of pending claims without need for escalation.
  • Reviewed COB cases and resolved payer discrepancies for commercial and Medicare members.
  • Ensured 100% adherence to HIPAA, SOX, and internal audit requirements.
  • Used HealthEdge and Availity to check eligibility and plan-specific coverage limits.
  • Tracked issue resolution through ServiceNow and maintained high SLA compliance.
  • Decreased claim rework by 19% through detailed review prior to submission.
  • Created onboarding materials to improve accuracy for new hires by 25%.

Education

Certified Billing and Coding Specialist (CBCS) -

Texas Southern University
Houston, TX
03-2020

HIPAA Compliance Certified -

Claims Processing Certification -

.

ICD-10/CPT Coding Certificate -

Remote Work Readiness Certificate -

Healthcare Compliance & Ethics Certificate -

Customer Service Excellence Certificate -

Microsoft Office Specialist – Excel -

EDI Claims Submission & Reconciliation Training -

Skills

  • Claims Processing
  • Claims adjudication
  • Medical billing
  • ICD-10 and CPT coding
  • Claims review
  • edi 837/835
  • UB-04/CMS-1500
  • Provider claims
  • Claim adjustments
  • Denial resolution
  • Appeals processing
  • Eligibility verification
  • Claim reconciliation
  • Pharmacy claims
  • Timely filing compliance
  • Healthcare claims audit
  • Medical terminology
  • Medicare and Medicaid
  • HIPAA compliance

Software System Expertise

  • Facets
  • EZ-CAP
  • Macess
  • HealthEdge
  • Availity
  • Salesforce
  • ServiceNow
  • Cognizant TriZetto
  • Microsoft Excel
  • QCare

Timeline

Healthcare Claims Processing Specialist

HCA Healthcare Hospital
03.2020 - Current

Medical Claims Adjudicator

HCA Healthcare Hospital
01.2017 - 02.2020

Pharmacy Claims Associate

Walgreens
08.2014 - 12.2016

Claims & Eligibility Coordinator

Texas Children Hospital
01.2012 - 08.2014

Certified Billing and Coding Specialist (CBCS) -

Texas Southern University

HIPAA Compliance Certified -

Claims Processing Certification -

.

ICD-10/CPT Coding Certificate -

Remote Work Readiness Certificate -

Healthcare Compliance & Ethics Certificate -

Customer Service Excellence Certificate -

Microsoft Office Specialist – Excel -

EDI Claims Submission & Reconciliation Training -

Similar Profiles

CREATE PROFILE
Barbara Williams