Crystal Mastandrea

• Interfaces with other insurance carriers as needed.
• Processes HMS reports; maintains accurate member Coordination of Benefits (COB) information; prepares, processes, and reconciles documentation from various internal departments; ensures accurate and timely payment of claims.
• Collect, analyze, and summarize data; properly submit claims for review, final determination, and possible payment.

Reviews pre-specified claims or claims that exceed specialist adjudication authority or processing

expertise.

• Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost containment measures to assist in the claim adjudication process.

• Handles phone and written inquiries related to requests for pre-approvals/pre-authorizations, reconsiderations, or appeals.

• Ensures all compliance requirements are satisfied and that all payments are made against company practices and procedures.

• Identifies and reports possible claim overpayments, underpayments and any other irregularities.

• Performs claim re-work calculations.

• Distributes work assignments daily to junior staff.

• Trains and mentors claim benefit specialists.

• Reviews pre-specified claims or claims that exceed specialist adjudication authority or processing expertise.
• Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost containment measures to assist in the claim adjudication process.
• Handles phone and written inquiries related to requests for pre-approvals/pre-authorizations, reconsiderations, or appeals.
• Ensures all compliance requirements are satisfied and that all payments are made against company practices and procedures.
• Identifies and reports possible claim overpayments, underpayments and any other irregularities.
• Performs claim re-work calculations.
• Distributes work assignments daily to junior staff.
• Trains and mentors claim benefit specialists.
• Makes outbound calls to obtain required information for First claim or re-consideration.
• Trained and equipped to support call center activity if required, including general member and/or provider inquiries.

• The Claims Review Analyst is responsible to correct claims, manage out of state processes, handle late submissions, process prompt pay interest, and responsible to respond to member bills.
• Responsible to research and review claims submissions based on provider request.
• Ability to determine pricing methodology for accurate payments.
• Ability to correct and adjudicate QHCM decisions and add interest as required.
• Research member submissions on balance billing.

• Performs work associated with claims received from institutional and professional providers; adheres to high quality standards; adheres to all federal, state, and organizational compliance standards when processing all claims.
• Input detailed data into customer accounts; document financial transactions in a timely fashion; utilize all technical documentation, including state/federal regulations and guidelines; ensure all customer accounts correctly reflect activity performed.
• Identify problems; examine solutions and options; implement action plans and provide resources; resolve quality issues.
• Retrieve and enter claims information in a computer database; open and review claims using available documentation; evaluate claim adjudication based on multiple payment methodologies (ex. RBRVS, APR-DRG, APG, APC).
• Analyze data; reconcile and resolve pending electronic reports; make recommendations.
• Create and process electronic claims submissions and understand related software programs.
• Familiarity with details of all government programs related to healthcare claims services necessary.

• Leads team of associates responsible for the accurate filing and archiving of all documents.
• File documents in accordance with established procedures for the Claims, Credentialing Department and Enrollment Departments.
• Serves as role model for maintaining a high level of professionalism and confidentiality while monitoring all activities.
• Work’s with team of associates to achieve department production and customer service goals.
• Oversees all requests for files as needed by the departments and deliver them in a timely fashion.
• Provides an accurate report of all internal requests.
• Views the Iron Mountain invoice to ensure requests are being billed properly.
• Oversees proper Archiving procedures when working with each department.
• Contact the Vendor of choice to pick up the files.
• Serves as a key operator for all major Audits that are needed for each Department.

• File documents in accordance with established procedures for the Claims, Provider Data Maintenance, Credentialing Department and Enrollment Departments.

• Interfaces with other insurance carriers as needed.
• Processes HMS reports; maintains accurate member Coordination of Benefits (COB) information; prepares, processes, and reconciles documentation from various internal departments; ensures accurate and timely payment of claims.
• Collect, analyze, and summarize data; properly submit claims for review, final determination, and possible payment.