Desharniece Green
San Jacinto,CA
Summary
Claims Examiner with deep knowledge of
Medical Claims industry. Solid abilities in developing objectives and strategies to resolve medical claims. Excellent skills compiling, coding, categorizing and auditing information to process claims.
Overview
15
15
years of professional experience
Work History
Provider Dispute Resolution Claim Examiner
LA Care Healthcare
06.2014 - Current
- Process claims for lines of business Medi-Cal, IHSS, DSNP former known CalMedi Connect (CMC) Medicare, L.A. Covered California.
- Proficiency in Microsoft Office application, Excel, Word, database management and Provider Facing Solution Expert.
- Reviewing Provider's complaint for the Department of Managed Health Care and ensuring the Department remains compliant of State & Federal Regulations.
- Research complex and severe claims problems, track and trend Provider issues, coordinate with various departments and entities to handle and resolve Provider's complaints submitted via the Department of Managed Health Care.
- Communicate clearly and concisely, with employee/colleagues at all levels, with exhibiting fundamental principles of writing and grammar, including proper report and correspondence format, provide document scope, project task in a clear and concise manner
- Plan, organize and prioritize work by managing and keeping track of multiple tasks, conform to shifting priorities, demands, and timelines through analytical and problem solving.
- Ensuring all work meets quality guidelines and performed within the applicable timeframe.
- Establish and maintain a strong interpersonal relationships with all level of staff, Departments and Regulatory agencies.
- Encourage and utilize suggestions and new ideals, while troubleshooting problem area, provide feedback to management team for possible training to ensure the Department remains in compliance of State & Federal regulations.
Claims Team Lead
Blueshield Of Ca
02.2008 - 06.2013
- Team Lead, back for the Supervisor of the Claims Department, liaison between all internal department, claim subject matter expert.
- Plan work for staff, organize and distribute priority work load, providing prompt communication with staff to ensure priority work is completed and all work meets quality guidelines and performance.
- Handle high level and complex issues, track and trend team work performance, answering internal and external questions and inquiries.
- Assist with process improvement, creating new policy & procedure in order to maintain up to date process and procedures.
Education
GED -
John C. Freeman
Los Angeles, CASkills
- Analytical and Critical Thinking
- Teamwork and Collaboration
- Organization and Time Management
- Multitasking Abilities
- MS Office Suite
- Problem-Solving
- Claim and Billing Resolution
- Payment Dispute Resolution
- Healthcare Provider Collaboration
- Compliant Resolution
Work Availability
monday
tuesday
wednesday
thursday
friday
saturday
sunday
morning
afternoon
evening
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Timeline
Provider Dispute Resolution Claim Examiner
LA Care Healthcare
06.2014 - Current
Claims Team Lead
Blueshield Of Ca
02.2008 - 06.2013
GED -
John C. Freeman
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