Diane James
Sewell,NJ
Summary
Seasoned Analyst with 20 years of experience in the healthcare industry. Expertise in claims processing, auditing and research, with a track record of identifying and recommending process improvements. Seeking to leverage extensive background in data analysis, problem-solving, and team leadership in an Analyst role.
Overview
22
22
years of professional experience
Work History
Claims Research Analyst
AmeriHealth Caritas Family Of Companies
11.2021 - Current
- Processes intricate provider project request according to plan requirements.
- Manages the processing of substantial claims exceeding $75,000 and addresses written inquires from providers.
- Resolves complex claim payment issues by offering technical solutions.
- Proposes enhancements and process improvements to streamline existing procedures.
- Provides comprehensive expertise and insights for the claims department.
- Consistently updates knowledge of processing rules to maintain accuracy and compliance.
Claims Quality Auditor
AmeriHealth Caritas Family Of Companies
11.2015 - 11.2021
- Performed comprehensive audits of professional and hospital claims, reinforcing financial precision and adherence to compliance standards.
- Managed audit validations with a specific on high-value claims over $50,000, reducing potential fiscal risks.
- Accurately recorded audit findings, facilitating issue detection and suggested efficient resolution approaches to leadership, while also aiding in the training of new team members by imparting expertise and best practices.
Provider Claims Service Representative
AmeriHealth Caritas Family Of Companies
05.2013 - 11.2015
- Oversaw and manage claim-related inquiries from provider for Medicaid recipients, guaranteeing timely and precise communication.
- Guided providers through the approval or rejection process of processed claims, fostering a thorough comprehension of the results.
- Corrected inaccurately processed claims in compliance with Medicaid guidelines, enhancing overall precision and productivity.
Physician Billing Specialist
Temple University Health System
03.2010 - 05.2012
- Oversaw accounts receivable operations, including processing credit adjustments and addressing returned checks, with a track record of achieving prompt resolution within the 30-day target period.
- Communicated with insurance providers to resolve denied claims and resubmitted.
- Analyzed complex Explanation of Benefits forms to verify correct billing of insurance carriers.
Staff Accountant
My House Management
12.2007 - 01.2010
- Monitored accounts receivable, accounts payable and other account balances to track transactions, avoid discrepancies and maintain accuracy.
- Prepared and processed journal entries to record in general ledger and maintain consistent documentation.
- Executed financial reporting, managing prepaid accounts, schedules, reconciliations, event settlements, and month-end accruals.
- Participated in internal and external audit processes to establish accurate financial records and comply with Generally Accepted Accounting Principles and regulatory requirements.
Claims Processor
Cigina International
01.2007 - 12.2007
- Utilized specialized software to process incoming claims, enter data and generate reports.
- Complied with regulations and guidelines related to claims processing to maintain quality and adherence to standards.
- Managed workload and priorities to meet claims processing meet deadlines.
Accounts Receivable Specialist
Mercy Health System
06.2006 - 01.2007
- Optimized accounts receivable procedures
- Proficiently handling credit adjustments, patient credits, voids and returned checks from Insurance companies.
- Followed up overdue payments and payment plans from clients to establish good cash flow.
- Monitored accounts to verify compliance with payment terms and schedules.
Physician Billing Specialist
Quality Community Health Care
11.2004 - 05.2006
- Communicated with insurance providers to resolve denied claims and resubmitted.
- Verified insurance of patients to determine eligibility.
- Collected payments and applied to patient accounts.
- Analyzed complex Explanation of Benefits forms to verify correct billing of insurance carriers.
- Posted payments and collections on regular basis.
Claims Analyst
Independence Blue Cross
05.2002 - 08.2004
- Conducted thorough analysis of claims application and corresponding medical documentation.
- Validating claims correctness and completeness by cross-checking with policy files and internal records.
- Referred most questionable claims to quality assurance or to claim adjusters for investigation.
- Maintained strict confidentiality with all personal data as per company guidelines.
Education
Associate of Science - Business Administration
Gwynedd Mercy University
Philadelphia, PA08.2014
Diploma - Medical Office Assistant
Star Technical Institute
Philadelphia, PA10.1997
Skills
- Facets
- Jiva
- Macess
- CORS Database
- Claims Auditing Database
- Medical Terminology
- MS Office
- Proficiency in Excel
- Data Analysis
- Problem Solving
- Critical Thinking
- Attention to detail
- Time Management
Timeline
Claims Research Analyst
AmeriHealth Caritas Family Of Companies
11.2021 - Current
Claims Quality Auditor
AmeriHealth Caritas Family Of Companies
11.2015 - 11.2021
Provider Claims Service Representative
AmeriHealth Caritas Family Of Companies
05.2013 - 11.2015
Physician Billing Specialist
Temple University Health System
03.2010 - 05.2012
Staff Accountant
My House Management
12.2007 - 01.2010
Claims Processor
Cigina International
01.2007 - 12.2007
Accounts Receivable Specialist
Mercy Health System
06.2006 - 01.2007
Physician Billing Specialist
Quality Community Health Care
11.2004 - 05.2006
Claims Analyst
Independence Blue Cross
05.2002 - 08.2004
Associate of Science - Business Administration
Gwynedd Mercy University
Diploma - Medical Office Assistant
Star Technical Institute