Gracie Perales

Analyzes claim trends related to data and helps identify inefficiencies and implement process improvement.

Provides guidance and support to all claims and operations personnel toward resolution of claim-related issues with an emphasis on root cause analysis and problem resolution.

Works with Claims Manager to develop new processes and procedures.

May act as a claims advocate with TMG (delegate) to ensure proper claims handling, including any necessary review, and addressing of coverage.

Continuous improvement approach to work and communicate changes needed for processes and develop updates as needed.

Lead problem solving in a team environment

Promote continuous learning and sharing of knowledge

Reviews on audit reports for targeted error-prone claims based on historical data and emerging trends.

Develops reporting processes and procedures to ensure timely delivery of daily, weekly, monthly, annual and ad hoc reporting to management.

Reviews and analyzes High Dollar Claims [HDOL-Pending Statuses] report.

Analyze oversight claims transactions in accordant with plan provisions.

Follows oversighted adjudicated claims from clearinghouse system based on covered benefits, insurance and provider contracts.

Reviews CMS submission and return reports in order to analyze gaps for potential greater error rates.

Supports reporting and analysis on all projects for claims initiatives.

Recommends and implements new or modified reporting methods and procedures to improve report content and completeness of information.

Assists in new implementation project(s) related to the claims department.

Trains and mentors staff as appropriate; manages relationships and acts as liaison with various business partners

Performs other duties as assigned.

• Identify Trending Issues by Examiner, Report Configuration Issues, Training Presentations, New Hire Orientation Presentations, Random Audits, Medicare Audit Prepping, Corrective Action Spreadsheets, Prepare for Compliance Week, Create and Distribute Monthly Audit Reports
• Analyzed financial data and prepared reports outlining findings and recommendations.
• Conducted risk assessments to identify potential areas of fraud or non-compliance.
• Performed regular reviews of the company's operations for compliance with laws and regulations.
• Assisted in preparing audit plans based on established objectives and standards.
• Drafted reports summarizing audit results while highlighting any irregularities or inconsistencies found during the process.
• Interacted regularly with clients to discuss audit progress, findings, and recommendations.
• Participated in special projects related to due diligence investigations as required.
• Monitored changes in applicable laws and regulations that affect the organization's operations.
• Maintained open communication with external auditors regarding coordination of audits.
• Ensured timely completion of all assigned tasks within set deadlines.
• Collaborated closely with other team members to develop effective audit plans.
• Researched industry trends related to regulatory requirements impacting the organization's operations.
• Conducted audits on internal controls and developed reports on findings.
• Maintained confidentiality of company information obtained in audit assignments.
• Analyzed balance sheets for mistakes and inaccuracies.
• Posted financial data in Excel spreadsheets and managed inventory.

• Audit Medicare Claims, Review Daily Checks for accuracy, Data Entry Reviews, Random Processor Audits, Adjust Claim Payments & Check Voids, Create and Distribute Monthly Audit Reports
• Conducted audits to ensure compliance with CMS regulations,Contract Agreements and Policy Plans and Company Standards.
• Identified potential fraud risks within the organization's operations.
• Assessed management's response to identified issues or problems related to internal controls or operational performance.
• Prepared reports detailing findings from all completed audits including recommendations for corrective action plans.
• Collaborated with other departments to ensure that any discrepancies were properly addressed in a timely manner.

• Performed audits of claims within the department, Adjust Monies & Claims, Reviewed high dollar medical claims, exceeding $20,000, Released high dollar medical claims with a $50,000 limit, Policy interpretations
• Investigated questionable claims to determine validity of payment requests.
• Identified trends in fraudulent or incorrect claims payments through analysis of audit results.
• Reviewed and audited claims to identify errors or discrepancies in the documentation.
• Evaluated policies and procedures for accuracy and adherence to state and federal laws.
• Tracked progress on implementation of corrective actions resulting from audits.