Camara Pruitt
Atlanta,GA
Summary
Proactive and goal-oriented professional with excellent time management and problem-solving skills. Known for reliability and adaptability, with swift capacity to learn and apply new skills. Experienced leader with strong background in guiding teams, managing complex projects, and achieving strategic objectives. Excels in developing efficient processes, ensuring high standards, and aligning efforts with organizational goals. Known for collaborative approach and commitment to excellence. Committed to leveraging these qualities to drive team success and contribute to organizational growth.
Overview
14
14
years of professional experience
Work History
Claims Representative
XO Health Inc
11.2024 - Current
- Processed and adjudicated medical claims efficiently, ensuring compliance with company policies and regulations.
- Collaborated with healthcare providers to gather necessary documentation for claims resolution.
- Trained new team members on claims processing procedures and system navigation.
- Priced and processed medical claims with outside vendors including First Choice and First Health.
- Work closely with Medical Professional Relations, Customer Service, and Support on pricing requests.
- Analyzed claim trends to identify areas for process improvement and reduce turnaround time.
- Analyzed claim discrepancies, facilitating prompt resolutions and improving customer satisfaction ratings.
- Secured proper payment for services rendered by thoroughly reviewing insurance coverages and applying appropriate codes.
- Correctly coded and billed medical claims for various hospitals and medical offices.
- Managed high-volume claim submissions, consistently meeting deadlines and maintaining a high level of accuracy.
- Supported departmental goals by working closely with team members to maintain consistent quality standards across all submitted claims.
Claims Specialist
United Health Group, Optum
12.2022 - 07.2024
- Handled inbound and outbound calls from members, pharmacies and providers.
- Analyzed Explanation of Benefits (EOB) and payment remittance documents submitted by healthcare providers and insurance carriers to determine which claims are eligible for the dispute resolution process.
- Communicated via email and phone with healthcare providers and health plans to obtain necessary information and relay the status of all claim submissions utilizing multiple different operating systems.
- Performed claim reviews for medical, pharmacy and behavioral health complex services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, correct coding for claims/operations.
- Performed pre-payment audits and posted payment audits to validate claims for appropriate coding and documentation (including but not limited to CPT, HCPCS, ICD-10 coding) and validated accurate claim adjudication rules and fee schedules.
- Provided coordination and processing of medical, behavioral health, and pharmacy prior authorization requests and/or appeals.
- Managed difficult, non-routine and escalated claims by using comprehensive research and thorough knowledge of Medicare payment rules.
- Identified and managed third party liability (TPL) or coordination of benefits (COB) cases reported by CMS, providers or members. Perform outreach and recovery efforts to Third Party Administrators.
Leave of Absence Coordinator
Opulence Innovative Solutions
12.2020 - 12.2022
- Responsible for coordinating the administration of Short-term Disability and FMLA plans
- Provided a timely and thorough review of Short-term Disability, FMLA, and ADA claims and made professional determinations.
- Managed the workflow for a large number of claims managed by the LOA/Disability Case Managers to ensure equitable workload distribution and administering of claims within department standards
- Provided advocacy case management to all appropriate LOA claims
- Managed high impact LOA claims to identify the obstacles and opportunities for returning associates to work
- Worked with the medical provider, LOA clinic resource, managers, and Local HR to determine the return to work expectations and to facilitate the return to work process
- Responsible for determining financial liability based on different claim factors.
Patient Access Representative
All Care Dental
10.2018 - 12.2020
- Collected and entered patient demographic and insurance data into computer database to establish patient's medical record
- Performed patient scheduling and registration functions to serve as initial contact point for medical office visits
- Obtained patient's insurance information and determined eligibility for benefits for specific services rendered
- Received patient deductibles and co-pay amounts and discussed options to satisfy remainder of patient financial obligations
- Explained estimated cost for medical treatments and answered patient questions to promote good understanding of proposed services
- Received, recorded and addressed incoming and outgoing communication via telephone and email
- Scheduled patient appointments in respective doctors' calendars and followed up with reminder phone calls
- Resolved patient financial problems with guidance from documented guidelines and procedures
- Secured patient information and confidential medical records in compliance with HIPAA privacy rule standards to protect patient's privacy.
Finance Manager
Nicholas Financial Inc
10.2017 - 10.2018
- Created strategies to develop and expand existing customer sales, resulting in increase in annual sales
- Supervised loan personnel and motivated to maintain customer service and performance standards
- Followed through with borrowers, loan processors, loan originators and managed all phases of underwriting process
- Obtained copies of applicants' credit histories and reviewed paperwork to determine feasibility of granting loans
- Monitored pipelines to track and log status of loans
- Established plans and payoffs for customers' loans, prioritizing control of overall costs
- Assessed aging accounts and initiated collection strategies based on conditions
- Developed prospects for new loans by conducting cold calls weekly
- Developed and updated spreadsheets and databases to track, analyze and report on performance and sales data
- Compiled database of loan applicants' credit histories, corporate financial statements and other financial information
- Evaluated debt ratio, loan-to-value ratios, credit scores property valuations and various other factors when making underwriting decisions.
Account Representative
American Credit Acceptance
08.2014 - 10.2017
- Developed new business relationships and maintained existing through regular communications and effective account management
- Arranged for debt repayment or establish repayment schedules, based on customers' financial situations as agreed / approved by collection manager
- Responsible for skip tracing a que of accounts ranging from 15- 90 days past due using TLO and accurint
- Created organizational structures to improve accounting and finance functions
- Liaised between internal and external stakeholders, clients and various external vendors to develop and implement client solutions
- Mitigated process gaps and managed financial operational functions
- Built relationships with customers and community to promote long term business growth
- Prioritized tasks and projects to meet tight deadlines
- Worked with sales team to collaboratively reach targets, consistently meeting or exceeding personal quotas
- Met or exceeded sales, customer service and loyalty program standards
- Identified new business opportunities through cold calling, networking, marketing and prospective database leads
- Met existing customers to review current services and expand sales opportunities
- Demonstrated consistent track record of overachieving sales quotas
- Maintained optimal financial controls by following loss prevention procedures and protecting cash assets
- Performed various administrative functions for assigned accounts, such as recording address changes and maintain current critical contract and credit information on debtors.
Insurance Claims Specialist
Loya Insurance
12.2011 - 04.2014
- Generated quotes and proposals for clients to match individual needs.
- Sold auto, home, and other various insurance products to individuals and affinity groups within assigned territory using consultative selling techniques.
- Provided expert advice on property and casualty insurance options, ensuring clients were well-informed to make educated decisions.
- Developed customized insurance plans for clients that balanced coverage requirements with budgetary constraints, ensuring long-term satisfaction with policy choices.
- Referred claims to other company units when necessary (e.g., Underwriting, Recovery Units or Claims Special Investigation Unit).
- Conducted thorough reviews of damages and determined the applicability of state law and other factors related to claims.
- Established strong rapport with clients through consistent communication, building trust as their trusted advisor on insurance matters.
Education
Bachelor's - Business Management
Georgia Military College
12.2017
Skills
- Account Management - 10 years
- Banking - 5 years
- Underwriting - 5 years
- Quality Assurance - 10 years
- Claims Processing
- Compliance Management
Timeline
Claims Representative
XO Health Inc
11.2024 - Current
Claims Specialist
United Health Group, Optum
12.2022 - 07.2024
Leave of Absence Coordinator
Opulence Innovative Solutions
12.2020 - 12.2022
Patient Access Representative
All Care Dental
10.2018 - 12.2020
Finance Manager
Nicholas Financial Inc
10.2017 - 10.2018
Account Representative
American Credit Acceptance
08.2014 - 10.2017
Insurance Claims Specialist
Loya Insurance
12.2011 - 04.2014
Bachelor's - Business Management
Georgia Military College
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