Carolyn A. Anderson
Florissant,MO
Summary
Objective is to learn, grow, and succeed with a dynamic organization utilizing knowledge in Medicare, Medicaid, & Ambetter
Overview
12
12
years of professional experience
Work History
Business Analyst I
Centene Corporation
03.2023 - Current
- Maintain and resolve provider pend inventory so that claims are not aged over 30 days to avoid PPP for Ambetter product
- Provide accurate claim processing instructions to claim shop to resolve claims pended for provider selection, pay class review, provider setup, configuration issues or billing issues
- Resolve all claim support task inquiries within expected UAT of 5 days
- Maintain the provider pend mailbox to make sure all inquiries/questions are addressed within a timely manner
- Create bulk load requests for providers to be added into Payment Index Management and update Honey Badger with correct pay class
- Create PRT tickets for Provider Data Management for claims/inquiries that need affiliation updates, taxonomy review, HAT code review, provider specialty updates, etc
- Review contracts in Icertis for rate table information, contract status, default percentages, etc
- Review weekly Cenpas inventory reports and resolve all cases for Ambetter provider pends
- Create daily spreadsheets in Excel with correct formatting and use excel functions such as v-lookup, concatenate, and pivot tables
- Create daily robotics request to get aged inventory processed as quickly and accurately as possible
- Use Golden queries daily to export reports for claim research and provider pend review.
Claims Liaison II
Centene Corporation
01.2020 - 03.2023
- Ran daily reports of Medicare claims inventory and give instructions on how to resolve claims quickly to alleviate claims aging past 15+ days
- Answered emails received from the plan and/or business analyst to resolve issues within a timely manner to avoid provider abrasion
- Effectively created and managed projects for claims that need to be reviewed or reprocessed due to benefit updates, provider configuration issues, claim process errors etc
- Proficient in working spreadsheets in excel and very knowledgeable on how to work excel functions such as v-lookup and pivot tables
- Pull and save files from PPS to complete and export the Power of BI reports and daily check run reports
- Reviewed, researched, and resolved claims that have known benefit, pricing, and contracting issues
- Requested check run corrections through the robotics submission application to alleviate as much manual work as possible
- Efficiently documented processes and any process changes to the check run guidelines
- Held monthly meetings with the health plan business analyst/ management to see if current issues being reviewed on the check run had been configured/resolved
- Reviewed PPS request form site daily to ensure any new processes were added to the check run guidelines and removed processes that have been resolved.
Claims Liaison I
Centene Corporation
10.2018 - 01.2020
- Served as a liaison between the plan, claims department, providers, and various departments to identify and resolve claim issues
- Proficient in excel and exporting spreadsheets from Golden to submit to claims with processing instructions
- Completed all projects accurately before the deadline date
- Researched and completed all pend reports and provided necessary pricing or processing instructions to claims
- Researched and resolved all OMNI inquiries that came from the provider or member
- Utilized the CMS website to ensure all Medicare pricing fees and policies and procedures were up to date and accurate.
Claims Analyst
Centene Corporation
02.2017 - 10.2018
- Researched and processed medical claims sent via electronic or mail
- Followed all processing guidelines to make sure first claim resolution was applied
- Reviewed pended, paid, and denied/rejected claims and determine if the status is accurate or if an adjustment should be made
- Kept daily tracker of each claim touched to provide accurate individual productivity
- Maintained and met quality scores each quarter
- Monitored and reviewed medical records
- Tracked any trends or system irregularities to help the adjudication process.
OIC Representative
Centene Corporation
05.2016 - 02.2017
- Received insurance verification requests from the database
- Initiated contact with Health Plans and followed-up on benefit coverage request and prior authorization
- Entered coverage information and coordination of benefit assignments.
Medicare Claims Specialist
Parallon Solutions
04.2014 - 05.2016
- Assisted patients with questions, inquiries, and payment options regarding their accounts
- Effectively maintained and resolved aging accounts assigned to lower interest applied
- Communicated third party payers, and providers to resolve patient accounts
- Researched and responded to all correspondence from insurance companies
- Printed and rebilled corrected claims electronically to be resubmitted to insurance
- Completed all necessary follow-up for accounts in insurance pending status
- Worked (RTP) returned to provider claims and issued corrections in DDE/FSS billing system.
Customer Service Representative
Cigna Insurance
09.2012 - 04.2014
- Received inbound calls from patients and healthcare professionals
- Answered questions about eligibility, coverage, and benefits
- Reviewed denied claims to see what information was needed to reconsider the claim
- Made outbound calls to patients and health care professional for additional information needed for claims resolution.
Education
College Degree in Medical Billing & Coding -
Sanford-Brown College-St Peters
St. Peters, MO04.2013
High school diploma -
Jennings Sr. High Graduate
St. Louis, MO01.2006
Skills
Microsoft Excel, Golden6, Portico, OMNI, Amisys, Honey Badger, Icertis, CenPas, CenProv, Webstrat, Microsoft Power BI Desktop, FileNet, & DST Provider Pricing, Knowledge of CPT and ICD coding, Exceptional ability to organize priorities and handle work life balance, Knowledge of Medicare, Medicaid, Marketplace & CBH LOB.
Timeline
Business Analyst I
Centene Corporation
03.2023 - Current
Claims Liaison II
Centene Corporation
01.2020 - 03.2023
Claims Liaison I
Centene Corporation
10.2018 - 01.2020
Claims Analyst
Centene Corporation
02.2017 - 10.2018
OIC Representative
Centene Corporation
05.2016 - 02.2017
Medicare Claims Specialist
Parallon Solutions
04.2014 - 05.2016
Customer Service Representative
Cigna Insurance
09.2012 - 04.2014
College Degree in Medical Billing & Coding -
Sanford-Brown College-St Peters
High school diploma -
Jennings Sr. High Graduate
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