Carolyn J. Dublin
Norfolk,VA
Summary
Highly motivated Office Practitioner experienced in claims configuration and analysis within healthcare systems. Achieved compliance with reimbursement methodologies and regulatory requirements through execution of configuration activities and thorough testing and documentation of changes. Focused on enhancing operational efficiency and resolving payment errors by supporting business requirements analysis for current and future markets.
Overview
1
1
Certification
29
29
years of professional experience
Work History
Provider Reimburse Admin Sr. Pricing Configuration Management (PCM)
ANTHEM, Inc.
Norfolk, VA
02.2017 - 04.2024
- Analyzed claims issues to identify root causes of payment errors, ensuring claims processing systems complied with contracted payment terms and regulatory requirements.
- Tests configuration changes to ensure claims are adjudicated according to reimbursement methodologies.
- Configured systems for new contracts, aligning with business requirements to support effective implementation.
- Assisted senior analysts in analyzing, documenting, configuring, and testing business requirements for current and future markets.
- Performs complex configuration activities under the oversight of more senior analysts.
- Resolved claim issues that were pended with the department and addressed phone logs forwarded to the department.
- The PRT/Process Director identifies whether the contract is an amendment, replacement or new contract.
Configuration Analyst I
ANTHEM Health Services
Virginia Beach, VA
01.2007 - 01.2017
- Executed configuration activities with guidance from senior analysts to ensure alignment with established processes.
- Tests configuration changes to ensure claims are adjudicated according to reimbursement Methodologies.
- Updated provider, member, and benefit configurations to ensure accurate claims processing.
- Configured Anthem health plan benefits within claims and enrollment systems.
- Supported senior analysts in analyzing, documenting, and testing business requirements for current and future markets.
- Performs analysis for claims issues to identify root causes of payment errors. This includes reviewing that the claims processing systems comply with contracted payment terms or state and federal requirements.
- Reviewed configuration changes against policy documents and system specifications.
- Assigned Conquest for contract configuration.
- The PRT/Process Director identifies whether the contract is an amendment, replacement or new contract.
Configuration QA Analyst
ANTHEM Health Services
Virginia Beach, VA
09.2004 - 01.2007
Subject Matter Expert
ANTHEM Health Services
Virginia Beach, VA
11.2002 - 09.2004
- Process advanced-level claim transactions, such as high-dollar reviews and others found in SME processing queues.
- Reviewed member cases, clarifying benefit details to ensure accurate support decisions aligned with member needs.
- Interpreted claims and coverage rules to resolve complex service issues, facilitating informed decision-making for stakeholders.
- Demonstrated proficiency in interpreting Medicaid contracts to ensure compliance.
- Advised Anthem Health Services teams on health plan policies and service procedures.
- Conducted performance reviews for team members, identifying specific areas for improvement to enhance overall team effectiveness.
- Provide input to the supervisor on developmental needs of team members.
- Serve as a mentor for newly trained analysts.
- Periodically run system queries as necessary.
Research Specialist
ANTHEM Health Services
Virginia Beach, VA
03.2002 - 11.2002
- Researched member eligibility records for Anthem Health Services case reviews.
- Reprocessed claims to resolve configuration keying and provider billing issues.
- Research claims from high profile providers from all markets.
- Ability to work effectively with external and internal customers and others by providing request information and solving problems.
- Adopted team concepts to enhance collaboration among team members. and work closely with other team members to meet deadlines standards.
- Ability to work effectively with external and internal customers and others by providing request information and solving problems.
- Reviewed claims data and policy documents to ensure accurate benefit interpretation.
Claims Analyst II
Member Services
07.2001 - 03.2002
- Processed complex claims transactions, resolving issues for claims personnel to enhance workflow.
- Administer a claims quality review program.
- Collaborated with Provider and Member Services personnel to address and resolve issues raised through member or provider communications.
Claims Analyst I
ANTHEM Health Services
Virginia Beach, VA
03.1999 - 07.2001
- Reviewed member claims for Anthem Health Services accuracy and policy compliance.
- Evaluate referrals, claims and encounters and enter information into an automated claims system according to employer policies and procedures.
- Adjusted previously entered claims and automated claims received, ensuring accuracy and adherence to guidelines.
- Performed quality control on the overall claims process according to employer job guidelines.
- Interpreted benefits, coverage rules, and claim edits for complex cases.
- Researched provider records and documentation for claim resolution.
Benefits Specialist
the New York Times Company, Shared Services Center
Norfolk, VA
12.1996 - 09.1998
- Administer the following benefits for 18,000 employees in 42 subsidiaries:
- Served Medical, Dental, Hearing/Vision, Life Insurance, Short and Long-term Disability, COBRA, FMLA, Flexible Spending Accounts, Employee Stock Purchase Plans, and 401K.
- Serve as liaison between insurance carriers and employees, determining eligibility, processing enrollment paperwork, and addressing benefit concerns.
- Assist benefit accountant with vendor reconciliation, ensuring accuracy and timeliness of benefit payments.
- Updated human resources information systems and organized employee benefits plan files for easy access.
- Report all unemployment (termination) claims to The Frick Company.
Customer Representative
Options Health Care
Norfolk, VA
04.1996 - 12.1996
- Established and nurtured clear verbal and written communication with insurance members and providers to ensure accurate information exchange.
- Responded to patient inquiries for health care services and coverage questions.
- Verified insurance details and updated customer records accurately.
Kindergarten Teacher
Carmel Christian Academy
Norfolk, VA
09.1995 - 03.1996
- Instructed one-on-one on basic care needs using creative activities like art, dance, and music to enhance learning engagement.
- Facilitated positive interactions and cooperation among children, engaging them in constructive conversations to develop essential skills for elementary school in a supportive and structured environment.
- Planned kindergarten lessons aligned with Carmel Christian Academy curriculum and biblical values.
- Taught early literacy, phonics, handwriting, and math through hands-on classroom activities.
- Managed classroom routines, behavior expectations, and smooth daily transitions.
Substitute Teacher
City of Norfolk Public School System
Norfolk, VA
05.1995 - 09.1995
- Designed and implemented engaging assignments and activities to enhance student learning.
- Created a structured environment that encouraged safe self-expression among students.
- Served as a role model for students to learn positive social values, attitudes and behaviors.
Benefits Specialist
Beverly Enterprises
Virginia Beach, VA
05.1995 - 09.1995
- Communicated with insurance representatives to facilitate processing and claims for medical, dental, and retirement insurance.
- Screened and processed incoming calls and written correspondence to address benefits inquiries and resolve issues.
- Coded, entered and processed employment data for enrollment, coverage, and termination, ensuring accurate benefits administration.
Education
Bachelor of Science - Business Administration
Elizabeth City State University
Elizabeth City, NCSkills
- Claims processing tools
- ICD-10
- ICD-9
- Medical coding
- Medical billing
- Healthcare compliance
- Healthcare benefits management
- Medicare
- Data reporting
- Data collection
- Data visualization
- Database administration
- Database systems
- Microsoft SQL Server
- Microsoft Access
- Microsoft Excel
- Microsoft Word
- Microsoft Office Suite
- Microsoft Outlook
- Microsoft Windows Operating Systems
- System configuration
- Process Improvement
- Analysis skills
- Quality Assurance
- Attention to detail
- Organizational skills
- Customer support
- Customer service
- Clerical experience
- Administrative experience
- Contract management
- Contract analysis
- Payroll
- HR support
- Logistics coordination
- Community outreach
- Market analysis
- System configuration
- PeopleSoft 51
- Workday
- Beyond Compare Software
- XML
- Visio
- People Tools 51
- Claims tracking systems
- Appeals
- Inpatient
- Statistics
- Business Requirements
- Call center
- Quality assurance
- Office systems knowledge
- Epic
- Administrative experience
- PeopleSoft 51
- Workday
- Medical coding
- ICD coding
- Clerical experience
- Contract analysis
- Benefits management
- Contract management
- Quality assurance
Personal Information
Driving License: Yes
Certification
Driver's License, Professional In Human Resources
Timeline
Provider Reimburse Admin Sr. Pricing Configuration Management (PCM)
ANTHEM, Inc.
02.2017 - 04.2024
Configuration Analyst I
ANTHEM Health Services
01.2007 - 01.2017
Configuration QA Analyst
ANTHEM Health Services
09.2004 - 01.2007
Subject Matter Expert
ANTHEM Health Services
11.2002 - 09.2004
Research Specialist
ANTHEM Health Services
03.2002 - 11.2002
Claims Analyst II
Member Services
07.2001 - 03.2002
Claims Analyst I
ANTHEM Health Services
03.1999 - 07.2001
Benefits Specialist
the New York Times Company, Shared Services Center
12.1996 - 09.1998
Customer Representative
Options Health Care
04.1996 - 12.1996
Kindergarten Teacher
Carmel Christian Academy
09.1995 - 03.1996
Substitute Teacher
City of Norfolk Public School System
05.1995 - 09.1995
Benefits Specialist
Beverly Enterprises
05.1995 - 09.1995
Bachelor of Science - Business Administration
Elizabeth City State University