Summary
Overview
Work History
Education
Skills
Timeline
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Billy Okumu

Bristol,PA

Summary

Proven Health Claims Specialist with a track record of enhancing claim processing efficiency and accuracy at Delaware Valley Trusts. Skilled in HIPAA compliance and claims processing, with a knack for strategic planning and decision-making. Boosted accuracy rates significantly, fostering strong relationships with insurance carriers and healthcare providers. Demonstrates exceptional problem-solving abilities and healthcare industry knowledge.

Overview

17
17
years of professional experience

Work History

Health Claims Specialist

Delaware Valley Trusts
02.2018 - Current
  • Assisted management with strategic planning initiatives by providing insightful analysis of claim data trends and performance metrics.
  • Implemented quality control measures that resulted in increased accuracy rates for submitted health insurance claims across the entire team''s portfolio.
  • Managed high-volume caseloads while maintaining strict attention to detail in order to ensure successful processing of each individual claim submission.
  • Served as a liaison between the billing department and insurance carriers, fostering positive relationships that led to smoother claim processing experiences for all parties involved.
  • Facilitated dispute resolution between patients, insurance companies, and healthcare providers, resulting in satisfactory outcomes for all parties involved.
  • Conducted regular audits of processed claims to ensure compliance with established procedures and regulatory requirements, minimizing financial risk for the organization.

Medicare Account Coordinator

Aetna Insurance Company
09.2012 - 02.2018
  • Streamlined communication between clients and internal teams for seamless project execution.
  • Ensured timely response to client inquiries by maintaining open lines of communication through email correspondence or phone calls.
  • Escalated issues to appropriate channels as necessary.
  • Fostered a positive work environment by actively participating in team-building activities and demonstrating commitment to the success of coworkers and clients alike.
  • Managed and maintained a portfolio of 22 Employer Group Health Plans (EGHP) focused on Medicare Advantage, Prescription Drug plans, and Cobra Health plans.
  • Supported senior account managers in strategic planning initiatives aimed at growing existing accounts or acquiring new business opportunities.

Complaint and Appeals Analyst

Aetna Insurance Company
07.2010 - 09.2012
  • Championed continuous improvement initiatives within the appeals department, implementing process enhancements that led to increased efficiency and productivity.
  • Followed department guidelines and tools to conduct reviews.
  • Collaborated with interdisciplinary teams to ensure accurate claims adjudication, reducing errors and inconsistencies in the review process.
  • Enhanced customer satisfaction with timely resolution of appeals, addressing concerns thoroughly and professionally.
  • Evaluated internal policies and procedures regularly to identify areas for improvement in the overall appeals process.
  • Conducted ongoing training sessions for staff on regulatory updates and new procedures, ensuring compliance with changing industry standards.
  • Utilized guidelines and review tools to conduct extensive research and analyze grievance and appeal issues.
  • Reviewed, analyzed and processed non-complex grievances and appeals.
  • Handled escalated cases adeptly, applying advanced problem-solving skills to resolve highly complex or contentious issues.

Claims Benefits Specialist

Aetna Insurance Company
01.2007 - 07.2010
  • Provided exceptional customer service by addressing client inquiries promptly and professionally.
  • Enhanced claim processing efficiency by streamlining workflows and implementing best practices.
  • Conducted comprehensive audits to identify areas of improvement within the claims process, leading to a more efficient system.
  • Decreased turnaround time for claim approvals with thorough investigation and efficient documentation.
  • Collaborated with medical professionals to obtain accurate information for proper benefit determination.
  • Stayed abreast of emerging trends relevant to the insurance industry as well as updated laws pertaining specifically to workers'' compensation programs.
  • Reviewed policy coverage details thoroughly before making determinations on benefits eligibility for each unique claim scenario presented.
  • Supported management in identifying areas of potential cost savings through the evaluation and implementation of alternative claim resolution strategies.

Education

Certificate, Health Savings Accounts (HSAs)

International Foundation of Employee Benefits
01.2024

MBA - Health Administration

Strayer University
Washington, DC
12.2015

BBA - Health Administration

Strayer University
Washington, DC
05.2013

Skills

  • Claims Processing Proficiency
  • HIPAA Compliance Understanding
  • Medical billing experience
  • Decision-making capabilities
  • Healthcare Industry Knowledge
  • Medical Terminology Familiarity
  • Knowledgeable in Microsoft Access; Outlook; Excel; PowerPoint; and Word
  • Insurance Claims

Timeline

Health Claims Specialist

Delaware Valley Trusts
02.2018 - Current

Medicare Account Coordinator

Aetna Insurance Company
09.2012 - 02.2018

Complaint and Appeals Analyst

Aetna Insurance Company
07.2010 - 09.2012

Claims Benefits Specialist

Aetna Insurance Company
01.2007 - 07.2010

Certificate, Health Savings Accounts (HSAs)

International Foundation of Employee Benefits

MBA - Health Administration

Strayer University

BBA - Health Administration

Strayer University

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Billy Okumu