James Johnson
La Habra,California
Summary
Claims Insurance Professional offering 30 + years in claims processing. Meticulous, systematic, and highly experienced with relationship-building abilities.
Service-oriented Claims Adjuster skilled at applying creative approaches to solving complex problems. Adept at developing profitable and quality-focused processes.
Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals. Claims Examiner with deep knowledge of Medicare, Medi-Cal and Insurance claims industry. Solid abilities in developing objectives and strategies to settle disputed claims. Excellent skills compiling, coding, categorizing and auditing information to process claims.
Overview
21
21
years of professional experience
Work History
Senior Claims Examiner
SCAN Health Plan
Long Beach, CA
01.2000 - 11.2020
Review DOFR to determine the correct payment source.
Review provider contracts to ensure correct claims payment or denial.
Review Insurance, Medicare, Medicare Advantage or Medi-Cal claims for correct processing procedures.
Research claims and incident information to deliver solutions and resolve problems.
Conduct administrative tasks to maintain information files and process paperwork.
Review provider inquiries to ensure proper payment or denial.
Request additional information from providers when adjudication can not be determined.
Submit additional information to Utilization Management for determination of claim payment or denial.
Education
No Degree - Pre Medicine
Moorhead State University
Moorhead, MN02.1974
High School Diploma -
Glenwood High School
Glenwood, MN06.1971
Skills
- Knowledge of CPT/HCPC and ICD-9 and ICD-10 codes and guidelines
- Comprehensive knowledge of DMHC and CMS guidelines to accurately adjudicate Commercial, Medi-Cal, and Medicare Advantage claims
- Process UB 92, HCFA 1500s, and COB claims
- Reviews, processes and adjudicate claims for payment according to Department's policy and procedures
- Processes all claims accurately conforming to quality and production standards and specifications in a timely manner
- Makes benefit determinations and calculations of type and level of benefits based on established criteria and benefits based on established criteria and provider contracts
- Understands and interprets health plan Division of Responsibilities (DOFR) and contract verbiage
- Determines out of network and out of area service providers and process in accordance with company and governmental guidelines
- Adjudicate Commercial, Medicare, Medicare Advantage, and Medi-Cal claims
- Ability to prioritize, multitask and manage claims assignment within company goals
Additional Information
Anaheim Memorial Medical Center - Process claims for all Memorial Health Services according to Hospital rules and procedures.
Long Beach Memorial Medical Center - Process Medi-Cal claims using State of California rules and regulations.
Huntington Memorial Hospital - Medi-Cal Supervisor ensuring proper billing of all Medi-Cal claims. Assisting patient with appling and followup for Medi-Cal eligibility.
Electronic Data Systems - Provider Relations Specialist - Assist providers with proper Medi-Cal billing and followup procedures. Help providers link to to online billing and payments.
Computer Sciences Claims - Review Medi-Cal claims for proper billing and payment. Report system problems to management for appropriate action. Review Treatment Authorizations to ensure correct Medi-Cal Billing.
Short Stop - Assistance Manager - Assist customers with purchases, stock inventory, balance daily totals, and make bank deposits of currency collected daily.
Timeline
Senior Claims Examiner
SCAN Health Plan
01.2000 - 11.2020
No Degree - Pre Medicine
Moorhead State University
High School Diploma -
Glenwood High School
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