Heather Stauch
Pleasant Hill,MO
Summary
Dynamic individual with hands-on experience in leadership and talent for navigating challenges. Brings strong problem-solving skills and proactive approach to new tasks. Possesses adaptability, creativity, and results-oriented mindset. Committed to making meaningful contributions and advancing organizational goals.
Overview
28
28
years of professional experience
Work History
Medical Claims Supervisor
GEHA
03.2023 - 12.2024
- Coordinated, supervised and was accountable for the daily, weekly and monthly activities of staff.
- Set priorities for the team to ensure task completion and performance goals were met such as quality, turn around time and other service levels.
- Coordinated work activities with other supervisors, managers, departments, etc.
- Identified and resolved operational problems using defined processes, expertise and judgement.
- Responsible for routine employee selection, performance and disciplinary decisions.
- Provided expertise and customer service support to members, customers and providers.
- Provided expertise and/or general claims support to teams in reviewing, researching, processing and adjusting claims.
- Authorized appropriate payment or refer claims to other departments for further review.
- Analyzed and identified trends and provided reports as necessary.
- Responded to claims appeals as needed by having the claims adjusted appropriately.
- Prepared and monitored section budget and expenditures.
- Recommended updates and creation of department policies and procedures, including quality improvements and workflow processes. Reviewed updates with staff to ensure understanding.
- Championed continuous improvement initiatives within the department, leading efforts aimed at operational excellence.
- Developed comprehensive reports on departmental performance metrics, informing executive-level decision making.
- Mentored junior staff, fostering professional growth and improving overall team performance.
- Enhanced customer satisfaction with timely resolution of complex medical claims.
- Participated in strategic planning sessions aimed at enhancing service offerings for clients in the managed care sector.
- Contributed to the creation of a positive work environment through open communication and proactive problem-solving initiatives.
Medical Claims Lead
GEHA
03.2021 - 03.2023
- Expedited claim resolution times with diligent follow-ups on pending claims, collaborating closely with healthcare providers and insurance carriers.
- Earned recognition for quality work and commitment to customer service excellence, consistently receiving positive feedback from both internal and external stakeholders.
- Strengthened relationships with healthcare providers by fostering open communication channels for discussing claim issues and negotiating payment arrangements.
- Enhanced the quality of customer service by addressing inquiries promptly, providing clear explanations of complex concepts and benefits.
- Reduced claim denial rates by accurately interpreting and applying policy guidelines and benefit coverage limitations.
- Delivered outstanding results under pressure by maintaining a high level of productivity during challenging periods of increased workload.
- Assisted new hires in developing their skills by sharing knowledge, answering questions, and offering guidance on best practices within the Medical Claims field.
- Improved claim processing efficiency by conducting thorough reviews of medical claims and identifying discrepancies.
- Supported departmental goals for cost containment by diligently investigating potential fraud cases and escalating suspicious activities as needed.
- Contributed to team success by supporting colleagues in handling large caseloads during peak periods, ensuring consistent productivity levels.
- Served as a reliable point of contact for escalated claim issues, providing expert guidance to colleagues and clients alike on resolution strategies.
- Streamlined internal processes for faster claims submission, implementing systematic document organization methods that improved overall efficiency.
- Played a key role in developing departmental policies aimed at improving overall operational effectiveness within the medical claims unit.
- Maintained knowledge of benefits claim processing, claims principles, medical terminology, and procedures and HIPAA regulations.
- Researched and resolved complex medical claims issues to support timely processing.
- Paid or denied medical claims based upon established claims processing criteria.
Specialized Medical Claims Adjuster
GEHA
08.2012 - 03.2021
- Analyzed policy details along with supporting documents provided by healthcare providers to make informed decisions on claims approvals or denials.
- Evaluated new software tools that improved productivity levels while maintaining accuracy standards.
- Resolved complex claims issues for expedited processing and resolution.
- Assisted in the creation of departmental procedures and guidelines to maintain consistency across all team members'' work quality standards.
- Identified patterns of fraudulent activities through meticulous analysis of medical claims data.
- Developed customized reports for management review, highlighting key trends and areas of improvement in claims handling process.
- Conducted thorough investigations of medical claims to ensure proper payment or denial.
- Maintained strict compliance with HIPAA regulations, safeguarding patient privacy throughout the claim evaluation process.
- Reduced claim processing time by streamlining medical claims adjudication processes.
- Enhanced team efficiency by training junior adjusters in industry best practices.
- Mentored new hires on company policies, procedures, and best practices related to medical claims adjusting.
- Managed high volume caseloads, prioritizing urgent and sensitive cases for immediate attention.
Claims Examiner/ PPO Payment Specialist
Summit America Insurance
02.2007 - 08.2012
- Process medical and accidental insurance claims for multiple groups with a variety of benefit plans both efficiently and accurately
- Compose letters to members as well as providers in order to obtain information needed to process charges received
- Review correspondence (member letters, medical records, etc.) to determine if information received will allow claims to be released for payment
- Upload monthly 'self bill' spreadsheets received from each of the PPO companies used, researching billed charges, coding charges in order to auto adjudicate, running auto adjudication of each batch of PPO payments and walking charges through the system that may not be able to auto adjudicate
Customer Service
The Epoch Group, LC
01.1997 - 01.2000
- Handle incoming calls from members and providers to verify benefits and check status of claims
- Update computer system with benefit information from each of the groups as needed
Education
High School -
01.1996
Skills
- Expertise in supervising team of associates
- Strong decision-making
- Claims processing efficiency
- Staff training and development
- Process improvement strategies
- Workflow optimization techniques
- Knowledgeable in various Microsoft Office Programs
- Scrupulous records management
Timeline
Medical Claims Supervisor - GEHA
03.2023 - 12.2024
Medical Claims Lead - GEHA
03.2021 - 03.2023
Specialized Medical Claims Adjuster - GEHA
08.2012 - 03.2021
Claims Examiner/ PPO Payment Specialist - Summit America Insurance
02.2007 - 08.2012
Customer Service - The Epoch Group, LC
01.1997 - 01.2000
Blue Springs Senior High School - High School,
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