Candi Larson
Schofield,WI
Summary
Skilled claims examiner with 12 years of experience in pharmaceutical and medical coverage/claims, utilizing strong customer service skills to resolve issues and ensure customer satisfaction. Experience in claims processing, medical records/documentation review, and fraud/waste/abuse detection, with a willingness to expand and learn new things. Proven ability to work effectively as a team player in a remote setting and has a drive to succeed in any role.
Overview
13
13
years of professional experience
Work History
Claims Examiner II
Wisconsin Physicians Services
10.2020 - Current
- Communicate with multiple departments, policyholders and healthcare providers to gather additional information or clarify claim/billing details
- Review records and claims flagged to the Program Integrity unit for accuracy, completeness, and compliance within TRICARE guidelines
- Claims processing for providers who are under review in the Program Integrity department
- Investigate and analyze claim documents, including medical records, in order to identify fraud, waste and abuse
- Identify and enter recoupments on claim payments for fraud, noncompliance, etc
- Work on fraud/waste/abuse claims/inquiries that come in from other departments, Humana or the Defense Health Agency for multiple TRICARE contracts
- Assist on projects in other departments during peak times of need
- Improved overall efficiency within the department by assisting in streamlining processes and eliminating redundancies where possible.
- Researched claims and incident information to deliver solutions and resolve problems.
- Mitigated fraud risks by identifying suspicious patterns in claims filing and escalating concerns as appropriate for further investigation.
- Managed large caseloads effectively while maintaining high-quality work standards and meeting strict deadlines consistently.
CSR - Customer Service Representative
OptumRx/United Health Care
05.2012 - 09.2020
- Provided exceptional customer service by promptly addressing inquiries, resolving issues, and ensuring customer satisfaction
- Assisted pharmacy techs to ensure accurate and prompt processing of pharmacy claims
- Handled billing inquiries including payment processing, adjustments, and account updates, as well as pharmacy help desk calls and coverage related inquires, accurately and efficiently
- Recognized as a top performer within the department based on consistently high levels of quality scores, average handle times, and customer satisfaction surveys
- Developed strong problem-solving skills through analyzing complex situations quickly while maintaining composure under pressure
- Mentored other team members to improve their performance metrics and enhance overall team productivity and performance
- Developed strong time management skills by efficiently prioritizing tasks and ensuring timely follow-up with customers
- Managed high call volumes, maintaining a professional demeanor during peak hours and effectively multitasking in a fast-paced environment.
- Demonstrated empathy and active listening skills, resulting in a higher rate of customer satisfaction and repeat business.
- Managed high-stress situations effectively, maintaining professionalism under pressure while resolving disputes or conflicts.
- Maintained detailed records of customer interactions, ensuring proper follow-up and resolution of issues.
- Resolved escalated customer issues, restoring confidence in company's commitment to service excellence.
Education
High school diploma -
Mosinee High School
Mosinee, WI05.1998
Skills
- Medical Records/Documentation review
- Claims processing
- Investigative skills / attention to detail
- Coverage / Eligibility Review
- Computer skills
- Fraud/Waste/Abuse detection
- Time management/ Multitasking
- Data entry
- Teamwork
- Effective communication
- Decision-making skills
- Organizational skills
Timeline
Claims Examiner II
Wisconsin Physicians Services
10.2020 - Current
CSR - Customer Service Representative
OptumRx/United Health Care
05.2012 - 09.2020
High school diploma -
Mosinee High School
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