Consuela Taylor
Hanover,MD
Summary
Detail-oriented Medical Insurance Claims Adjuster with over 5 years of experience reviewing, analyzing, and processing healthcare claims in compliance with policy provisions, state regulations, and HIPAA guidelines. Skilled in medical terminology, CPT/ICD-10 coding review, benefits determination, and provider negotiations. Known for accuracy, efficiency, and strong provider/member communication.
Overview
7
7
years of professional experience
1
1
Certification
Work History
Claims Adjuster
Advanced Revenue Solutions
01.2025 - Current
- Examined claims forms and other records to determine insurance coverage.
- Answered customer questions regarding deductibles.
- Conducted comprehensive interviews of witnesses and claimants to gather facts and information.
- Verified insurance claims and determined fair amount for settlement.
- Review and adjudicate 80–120 medical claims daily, ensuring accuracy and compliance with policy guidelines.
- Analyze CPT, ICD-10, and HCPCS codes to determine appropriate reimbursement levels.
Behavioral Health Biller
All Points North
07.2022 - 01.2026
- Identified, researched, and resolved billing variances to maintain system accuracy and currency.
- Executed billing tasks and recorded information in company databases.
- Followed up with appropriate parties to obtain prompt payments.
- Kept all patient information secure and confidential.
- Processed insurance company denials by auditing patient files, researching procedures, and diagnostic codes to determine proper reimbursement.
- Interacted with physicians and other healthcare staff to ask questions regarding patient services.
- Correctly coded and billed medical claims for various hospital and nursing facilities.
- Checked employees' benefits enrollment for accuracy and inputted all data into Sales Force.
Claims Analyst
Maxium Healthcare
01.2019 - 07.2022
- Processed high-volume medical and dental claims with 98% accuracy rate.
- Reviewed medical documentation to validate services and prevent overpayments.
- Assisted members with benefit inquiries and claim status updates.
- Identified billing irregularities and referred potential fraud cases to SIU.
- Improved claim turnaround time by 12% through workflow optimization.
- Reviewed provider coding information to report services and verify correctness.
- Paid or denied medical claims based upon established claims processing criteria.
- Followed up on denied claims to verify timely patient payment and resolution.
- Verified patient insurance coverage and benefits for medical claims.
Education
High School Diploma -
Continental Academy
Miramar, FL06-2006
Skills
- Medical Claims Processing
- Benefits & Coverage Determination
- CPT / ICD-10 / HCPCS Coding Review
- EOB (Explanation of Benefits) Preparation
- Medicare & Medicaid Regulations
- HIPAA Compliance
- Appeals & Grievance Handling
- Fraud, Waste & Abuse Identification
- Provider & Member Communication
- Claims Management Systems (Facets, QNXT, Epic, etc)
Certification
- CMC - Certified Medical Coder
Timeline
Claims Adjuster
Advanced Revenue Solutions
01.2025 - Current
Behavioral Health Biller
All Points North
07.2022 - 01.2026
Claims Analyst
Maxium Healthcare
01.2019 - 07.2022
High School Diploma -
Continental Academy