Belen To

- Consistently met day to day deadline and delivered high quality work,demonstrating a strong commitment to excellence in record keeping and management

- Created/updated member records in Tapestry accurately with appropriate notations

- Verified eligibility utilizing health plan websites and/or call health plans for accurate records

- Identified non member claims and documents accordingly each case clearly in support of mail back notification process

- Updated correct claim rejects from EDI files before these are loaded to the system.

- Analyzed/updated/corrected pended claims

- Worked on eligibility clean up project when needed

ELIGIBILITY

- Maintained accurate data on eligibility -verifying, creating and updating member records while meeting day to day deadline

- Updated and corrected claim rejects from EDI files before these were loaded in the system

- Analyzed,updated/corrected pended claims

- Worked on Eligibility clean up project when needed

- Prepared desk procedures and processed documents to ensure continuous, non interruption of services to functional department

- Analyzed , loaded and updated SHC Advantage member records extracted from UHCA Application Manifest and WiPro files

- Resolved all inquiries, briefcases and helpdesk tickets

relating to SHC Advantage members including but not limited to updating member records

- Ran the daily WiPro files report and prepared the spreadsheet used as reference by the Advantage and MIS team

- Prepared the daily communication of the files of UHCA member ID cards sent to the Advantage Operations and Data teams

ENCOUNTERS

- Navigated to clearing houses and third vendor portals fluently the functionalities of each portal

- Fixed and resolved enrollment enrollment systems rejection in the portal

- Collaborated eligibility issues and encounter data issues with internal customer in the registration and claim payment process

- Collaborated eligibility and encounter data issues with external vendors and health plans

PROVIDER INFORMATION AND CONTRACTS

- Loaded and updated provider information and configure contracts in the system to maintained it it as accurate as possible

- Identified and analyzed provider issues and resolved helpdesk tickets submitted by Claims, Contracting, Quality and Clinical Departments

- Supported claim department relating to provider payments, claim pends and contract discrepancies

- Closely worked with Business Systems Analyst on provider questions/issues that need resolutions and worked on provider clean up

- Assisted and trained new team members/temps on the policies and procedures, work flows and system issues

- Supported and maintained main transactions and other supporting systems functionality (eligibility, provider, benefit plans, claims, encounters)

- Processed and resolved professional and institutional medical claims with information issues including missing incorrect codes, member eligibility, provider contracts and benefits

- Provided quality assurance and testing expertise

- Identified improvements in work flows or systems and collaborated with the Data Integration Team to implement necessary changes

- Trained new members in all facets of operation - eligibility, benefits and encounters

- Prepared and monitored the authorization letters, mailing files and responsible for the monthly payment audit for the vendors

- Processed claim refunds for Claim Recovery Project

- Provided assistance on daily operational tasks of Information Systems Department, mostly clearing claim rejects

- Handled daily claim mail backs with specified timeline