Iris Brice

Investigated and responded to all inquiries and complaints that are received by phone, mail, fax or online from TPA Providers and Internal Departments.

Identified, researched, and corrected problematic claims and respond to TPA inquiries regarding priced claims discrepancies.

Investigated missing or invalid Membership data for claims held in the external claims edit screen by using a validation process that involves access to membership data in Facets prior to the claim being updated or denied. Contact to the Third-Party Administrators may be required to resolve the membership discrepancy.

Partnered closely with other departments to rectify any claims issues or workflow holds, and obtain information relating to an inquiry or complaint, resolution, ensuring compliance, company standards, and TPA SLAs.

Attended all TPA meetings. Used my problem solving skills by thoroughly investigating issues or concerns; analyzed all information and made recommendations for appropriate course of action towards resolution and/or process improvements.

Identified and reported system configuration issues to the Business Configuration Team.

Met all corporate standards such as quality, quantity, HIPAA, DOL and NCQA.

Assisted with the yearly Aetna Audit. Maintained all of the Aetna Rework claims that we received back for reprocessing. Also assisted with any special projects that were assigned for our Aetna claims.