Brenda Yarbrough
Euclid
Summary
Effective Medical Claims Processor with strong background building rapport with providers to discuss claim status or claim denials. Driven performer equipped to handle multiple administrative tasks effectively. Exemplary worker with highly investigative skills when processing claims.
Overview
15
15
years of professional experience
Work History
Medical Claims Examiner
Roundstone
09.2020 - 05.2023
- Review and verify member claims information following standard operating policies and procedures
- Ability to process and validate all claim types/queues accurately
- Cross functional “flex” team member as needed (by platform or department)
- Data entry
- Provided excellent Customer service to members and providers
- Quality and accuracy at 98% while following PHI and HIPPA regulations
- Production remained between 150-250 per day
- Team remained at less than 5% of claim under14 days for 4 months
- Facilitated training programs for the claims and customer service departments
- Provided continued support to team by providing, feedback, and training as needed
- Coordinated with previous Claim Operation Manager, COO and Director of Customer Experience in implementation of new claims and phone system, polices, and procedures
- Managed large volume of medical claims on daily basis
- Followed up on potentially fraudulent claims initiated by claims representatives
- Restocked supplies and placed purchase orders to maintain adequate stock levels.
- Executed record filing system to improve document organization and management.
- Scheduled office meetings and client appointments for staff teams.
- Established productive working relationships with public officials and law enforcement officers
- Collected and tracked evidence in support of legal processes
- Reviewed and analyzed suspicious and potentially fraudulent insurance claims
- Reviewed provider coding information to report services and verify correctness
- Tracked progress of short- and long- term goals and assisted in strategic planning
- Assisted established management staff with operational oversight, business development and process improvement strategies
- Developed positive rapport with both management personnel and employees to facilitate effective communication and collaboration
- Assisted manager in planning and implementing strategies to meet organizational goals.
- Paid or denied medical claims based upon established claims processing criteria.
- Maintained knowledge of benefits claim processing, claims principles, medical terminology, and procedures and HIPAA regulations.
- Verified patient insurance coverage and benefits for medical claims.
- Assessed medical claims for compliance with regulations and corrected discrepancies.
- Managed large volume of medical claims on daily basis.
- Monitored and updated claims status in claims processing system.
- Reviewed provider coding information to report services and verify correctness.
- Identified and resolved discrepancies between patient information and claims data.
- Evaluated medical claims for accuracy and completeness and researched missing data.
- Used administrative guidelines as resource or to answer questions when processing medical claims.
- Generated reports on medical claims processing activities and results.
- Responded to correspondence from insurance companies.
- Researched and resolved complex medical claims issues to support timely processing.
- Answered multi-line phone system, routing calls, delivering messages to staff and greeting visitors.
Claims Representative II
Medical Mutual
10.2018 - 09.2020
- Of Ohio and Its Family of Companies
- Shared knowledge and expertise with co-workers to foster awareness and increase staff productivity
- Processing claims for payment
- Analyzing procedures to fit each claim's need
- Slashing our claims by 35%
- Approving and rejecting claims for payment
- Processing 300 claims day with 98% accuracy while following PHI and HIPPA regulations
- Processed and recorded new policies and claims
- Modified, updated and processed existing policies
- Coordinated with contracting department to resolve payer issues.
Claims Support Specialist
Selman And Company
04.2017 - 10.2018
- Interviewed policyholders to verify information and obtain additional details
- Clerical and administration duties
- Answered multi-line phone system, routing calls, delivering messages to staff and greeting visitors.
- Intake process of new claim
- Restocked supplies and placed purchase orders to maintain adequate stock levels.
- Processes checks and explanation of benefits
- Ordering Medical and Police Records and summaries for claims
- Analyzing insurance policy coverage and determining eligibility
- Executed record filing system to improve document organization and management.
- Processing claims for policy holder
- Processed payments for TRICARE & CHAMPVA Supplemental Insurance claims
- Examined reports, accounts and evidence to determine integrity and accuracy of information
- Followed up with customers on unresolved issues
- Checked level and type of coverage and evaluated contracts
- Posted payments to accounts and maintained records
- Coordinated with contracting department to resolve payer issues
- Maintained strong knowledge of basic medical terminology to better understand services and procedures
- Modified, updated and processed existing policies.
- Worked productively in fast-moving work environment to process large volumes of claims.
- Analyzed and addressed escalated claims to resolve issues quickly.
Claims Assistant
Sedgwick CMS
09.2015 - 04.2017
- Contact loss participants or vendors for information at request of claims staff
- Create and mail appropriate claim correspondence
- Order records and reports applicable for claims processing
- Assist with workload and workflow management by monitoring claims systems, distributing workload and completing profile updates
- Work on daily maintenance and update of assigned tasks, correspondence, etc
- Generate various weekly/monthly reports
- Develop basic understanding of insurance industry and organizational relationships of company
- Develop basic understanding of functions of other departments, such as Policy Ops and Marketing
- Develop basic understanding of systems and technology used within company
- Investigating policy to determine coverage
- Investigated claims for possible fraud
- Processed claims for up to $10,000.00
- Logged, allocated and managed claims
- Prepared files, letters and notices
- Examined reports, accounts and evidence to determine integrity and accuracy of information
- Interviewed policyholders to verify information and obtain additional details
- Created and updated VBA tracking spreadsheets
- Followed up with customers on unresolved issues
- Worked productively in fast-moving work environment to process large volumes of claims
- Checked level and type of coverage and evaluated contracts
- Reviewed outstanding requests and redirected workloads to complete projects on time
- Generated, posted and attached information to claim files
- Processed and recorded new policies and claims.
- Prepared files, letters and notices.
- Logged, allocated and managed claims.
- Created and updated VBA tracking spreadsheets.
- Worked productively in fast-moving work environment to process large volumes of claims.
Education
Bachelor of Science - Human Resource Management
Ashland University
Certificate of Completion: Dental Assisting -
Cleveland Institute of Dental-Medical Assistants
Mentor, OH06.2011
High School Diploma -
Health Careers Center High School
Cleveland, OH06.2005
Skills
- Claims Processing
- Customer Service
- Analysis Skills
- Claims Support
- ICD-10
- Retail Management
- Medical terms and procedure knowledge
- Health insurance industry knowledge
- Claims
- Active Listening
- Telephone Etiquette
- Financial Assistance
- CRM Software
- Detailed Meeting Minutes
Timeline
Medical Claims Examiner
Roundstone
09.2020 - 05.2023
Claims Representative II
Medical Mutual
10.2018 - 09.2020
Claims Support Specialist
Selman And Company
04.2017 - 10.2018
Claims Assistant
Sedgwick CMS
09.2015 - 04.2017
Bachelor of Science - Human Resource Management
Ashland University
Certificate of Completion: Dental Assisting -
Cleveland Institute of Dental-Medical Assistants
High School Diploma -
Health Careers Center High School
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