James Johnson
La Habra,CA
Summary
Senior Claims Examiner III. Deep knowledge of both Medi-Cal and Medicare claims industry. Solid abilities in developing objectives and strategies to settle technical claims. Excellent skills compiling, coding, categorizing and auditing information to process claims.
Overview
24
24
years of professional experience
Work History
Senior Claims Specialist
Kinetic Personnel Group
05.2023 - 11.2023
- Six month assignment as customer service representative.
- Managed approximately 30 incoming calls, emails and faxes per day from providers.
- Enhanced team productivity by providing ongoing training to junior claims specialists on best practices and industry trends.
- Boosted customer satisfaction ratings by providing prompt responses to inquiries and resolving issues within timely manner.
- Maintained up-to-date knowledge of industry regulations, legal developments, and emerging risks to ensure company readiness for any challenges that may arise.
Senior Claims Examiner
SCAN Health Plan
01.2000 - 11.2021
- Streamlined claims processing by implementing efficient workflow procedures.
- Reduced claim resolution time by conducting thorough investigations and timely decision making.
- Researched claims and incident information to deliver solutions and resolve problems.
- Handled complaints and grievances using negotiating and problem-solving skills
Education
No Degree - Pre-Medicine
Moorhead State University
Moorhead, MN04.1972
High School Diploma -
Minnewaska Secondary
Glenwood, MN06.1971
Skills
- Comprehensive Knowledge of DMHC and CMS guidelines to accurately adjudicate Commercial, Medi-Cal, and Medicare Advantage claims
- Process UB 92, HCFA 1500, and COB claims Reviews, processes and adjudicate claims for payment according to Departments policy and procedures
- Understands and interprets Health Plan Divisions of Financial Responsibility (DOFR) and contact Verbiage
- Determines out of network and out of area service providers and process in accordance with company and government guidelines,
Timeline
Senior Claims Specialist
Kinetic Personnel Group
05.2023 - 11.2023
Senior Claims Examiner
SCAN Health Plan
01.2000 - 11.2021
No Degree - Pre-Medicine
Moorhead State University
High School Diploma -
Minnewaska Secondary
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