Doreen Schady-Thomson
Loch Sheldrake,NY
Summary
Proven Medical Claims Examiner from Maxon with a track record of enhancing claim processing efficiency and productivity by over 30%. Expert in HIPAA compliance and claims processing, coupled with exceptional customer service skills. Achieved significant improvements in interdepartmental communication and fraud detection, demonstrating strong problem-solving abilities and attention to detail.
Overview
28
28
years of professional experience
Work History
Medical Claims Examiner
Maxon
05.2015 - Current
- Enhanced claim processing efficiency by conducting thorough investigations and maintaining accurate documentation.
- Increased productivity by implementing efficient strategies for handling high volumes of medical claims daily.
- . Achieved excellent outcomes for both patients and healthcare providers by applying sound judgment in adjudicating complex medical claims.
- Improved interdepartmental communication by fostering a collaborative environment and sharing vital information regarding complex cases.
- Reduced errors in claim submissions by meticulously reviewing patient information and verifying insurance eligibility.
- Provided exceptional customer service, addressing concerns from policyholders and answering inquiries related to their claims status.
- Identified fraudulent activities by analyzing patterns, trends, and discrepancies in medical claims data.
- Continuously sought opportunities for process improvement, contributing innovative ideas to enhance overall departmental efficiency and effectiveness.
- Assisted in the training and onboarding of new team members, sharing knowledge and best practices to ensure their success.
- Streamlined workflow for faster resolution of medical claims through effective prioritization and organization.
- Collaborated with healthcare providers to obtain necessary medical records, ensuring timely and accurate claim adjudication.
- Managed large volume of medical claims on daily basis.
- Identified and resolved discrepancies between patient information and claims data.
- Monitored and updated claims status in claims processing system.
- Maintained knowledge of benefits claim processing, claims principles, medical terminology, and procedures and HIPAA regulations.
- Verified patient insurance coverage and benefits for medical claims.
- Paid or denied medical claims based upon established claims processing criteria.
- Evaluated medical claims for accuracy and completeness and researched missing data.
- Generated reports on medical claims processing activities and results.
- Assessed medical claims for compliance with regulations and corrected discrepancies.
- Reviewed provider coding information to report services and verify correctness.
- Used administrative guidelines as resource or to answer questions when processing medical claims.
- Followed up on denied claims to verify timely patient payment and resolution.
- Processed insurance payments and maintained accurate documentation of payments.
- Interviewed agents and claimants to correct errors or omissions and investigate questionable claims.
- Delivered exceptional customer service to policyholders by communicating important information and patiently listening to issues.
- Examined claims forms and other records to determine insurance coverage.
- Identified insurance coverage limitations with thorough examinations of claims documentation and related records.
- Conducted day-to-day administrative tasks to maintain information files and process paperwork.
- Researched claims and incident information to deliver solutions and resolve problems.
- Analyzed information gathered by investigation and reported findings and recommendations.
- Reviewed police reports, medical treatment records, and physical property damage to determine extent of liability.
- Reviewed questionable claims by conducting agent and claimant interviews to correct omissions and errors.
- Determined liability outlined in coverage and assessed documentation such from police and healthcare providers to understand damages incurred.
Schedule Coordinator
Pediatric Specialty Group
01.2015 - 05.2015
- Streamlined internal communication, ensuring accurate and up-to-date schedule information for all team members.
- Managed last-minute schedule changes with minimal disruption to daily operations or customer service levels.
- Addressed any personnel concerns related to work schedules promptly, promoting a positive working environment for all staff members.
- Enhanced customer satisfaction with timely coordination of appointments and service requests.
- Collaborated with department managers to resolve scheduling conflicts and ensure smooth operations.
- Provided support during periods of high demand by stepping in as needed to cover shifts or manage urgent tasks effectively.
- Evaluated current scheduling processes, identifying areas of improvement to increase overall efficiency.
- Oversaw appointment scheduling and itinerary coordination for both clients and personnel.
Customer Service Representative
Private Island Party
07.2014 - 12.2014
- Managed high-stress situations effectively, maintaining professionalism under pressure while resolving disputes or conflicts.
- Resolved customer complaints with empathy, resulting in increased loyalty and repeat business.
- Handled escalated calls efficiently, finding satisfactory resolutions for both customers and the company alike.
- Responded to customer requests for products, services, and company information.
- Enhanced customer satisfaction by promptly addressing concerns and providing accurate information.
- Developed strong product knowledge to provide informed recommendations based on individual customer needs.
- Developed rapport with customers through active listening skills, leading to higher retention rates and positive feedback from clients.
- Assisted customers in navigating company website and placing online orders, improving overall user experience.
Medical Receptionist
Planned Parenthood
01.1997 - 10.2008
- Coordinated patient scheduling, check-in, check-out and payments for billing.
- Checked patient insurance, demographic, and health history to keep information current.
- Helped patients complete necessary medical forms and documentation.
- Maintained strict confidentiality of patient information, adhering to HIPAA regulations and medical office policies.
- Adhered to strict HIPAA guidelines to protect patient privacy.
- Managed high call volumes, directing calls to appropriate departments while maintaining a polite and professional demeanor.
- Managed multi-line phone system and pleasantly greeted patients.
- Provided compassionate customer service, creating a welcoming atmosphere for patients and their families.
- Maintained current and accurate medical records for patients.
- Enhanced patient satisfaction by efficiently managing the front desk operations and addressing inquiries in a timely manner.
- Developed strong relationships with patients, fostering loyalty and trust in the practice''s services.
- Assisted healthcare providers with administrative tasks, enabling them to focus on quality patient care.
Education
High School Diploma -
Pine Bush Senior High School
Pine Bush, NYSkills
- Customer service focus
- Claims Processing Proficiency
- HIPAA Compliance Understanding
- Professionalism and Ethics
- Medical Terminology Familiarity
- Interpersonal abilities
- Documentation Review
- Data Entry Efficiency
- Medical Coding Expertise
- Medical record review
- Insurance claims processing
- Quality assurance checks
- Thorough claims reviews
- Organizational abilities
- Insurance Verification
- Critical Decision-Making
- Telephone Etiquette
- Provider Relations
- Inpatient records coding
- Insurance Claims
- Fee Billing
- Claim validity determination
- ICD Codes
- Electronic Claims Processing
- Electronic Health Records (EHR)
- Teamwork and Collaboration
- Problem-Solving
- Insurance policy knowledge
- Time Management
- Attention to Detail
- Problem-solving abilities
- Multitasking
- Claims Investigation
- Excellent Communication
- Customer service and support
Timeline
Medical Claims Examiner
Maxon
05.2015 - Current
Schedule Coordinator
Pediatric Specialty Group
01.2015 - 05.2015
Customer Service Representative
Private Island Party
07.2014 - 12.2014
Medical Receptionist
Planned Parenthood
01.1997 - 10.2008
High School Diploma -
Pine Bush Senior High School