Janelle Sustiguer
Phoenix
Summary
Innovative technology professional with several years of diverse experience. Skilled in enhancing systems and aligning technical solutions with business objectives. Proven success in leading projects from start to finish and contributing to organizational growth and success.
Overview
11
11
years of professional experience
Work History
Claims Specialist/Stop Loss Coordinator
Vault Admin Services
04.2025 - Current
- Ensured accurate claims adjudication, enhancing compliance and process efficiency.
- Facilitated thorough management reviews for elevated claims exceeding limits.
- Validated vendor invoices, guaranteeing timely payments for healthcare providers.
- Maintained precise records of invoices from Cigna PBM and vendors.
- Reviewed high-dollar claims, identifying those surpassing established thresholds.
- Submitted complete stop-loss reimbursement claims, ensuring compliance with documentation standards.
Member/Provider Advocacy Manager
Advanced Medical Pricing Solutions
09.2019 - 12.2024
- Achieved 90% account retention by effectively liaising with TPAs and brokers.
- Strengthened partnerships through proactive engagement and relationship-building initiatives.
- Enhanced service delivery by identifying inefficiencies, ensuring 90% compliance rates.
- Increased member satisfaction by 20% using insights gained from CSAT audits.
- Conducted comprehensive staff training, boosting overall team performance significantly.
- Monitored metrics, achieving 90% compliance while significantly reducing call durations.
Patient Accounts Payable/Receivable Specialist
AVP, Barnet Dulaney Perkins Eye Center
12.2017 - 09.2019
- Achieved 99% accuracy in financial records through thorough billing reviews.
- Ensured error-free transactions by meticulously verifying insurance and billing details.
- Improved payment timeliness by efficiently preparing and sending invoices to clients.
- Reduced outstanding balances by 20% through proactive invoice management and follow-ups.
- Increased operational efficiency by 25% via system upgrades and comprehensive staff training.
- Streamlined scheduling and insurance checks, enhancing patient service and minimizing delays.
Resolution Supervisor
OptumRx
09.2014 - 12.2017
- Reduced onboarding time by 30% through effective training supervision.
- Increased prescription resolution efficiency, cutting average time by 10%.
- Boosted customer service resolution efficiency by 20% using data-driven solutions.
- Enhanced customer satisfaction by 15% with standardized training protocols.
- Minimized documentation errors by 10% while ensuring HIPAA compliance.
- Achieved 20% reduction in escalations by optimizing workflows and improving resolutions.
Education
High School Diploma -
Teenage Parent Program
Tucson, AZSkills
- Claims
- Claims processing
- Claims investigation
- Verbal communication
- Microsoft office
- Time management
- Decision-making
- Critical thinking
- Customer service
- Organizing and prioritizing work
- Multitasking Abilities
- Medical terminology
Accomplishments
- Developed comprehensive processes and procedures for the "Binder" system, enhancing operational efficiency.
- Designed and applied detailed workflows aimed at effectively training and onboarding new hires, ensuring a smooth integration into the team.
- Actively volunteered for youth events in the community, contributing to mentorship and positive engagement with young people.
- Coordinated trio meetings and managed on-site projects at AFNI, fostering collaboration and teamwork among participants.
- Played a key role in organizing job fair initiatives at IQOR, facilitating connections between job seekers and potential employers.
- 2020, 2022, 2023 Customer Service of Excellence Award – Manager
- October 2023 – Employee Highlight of the Week – Demonstrating leadership, creativity, & mentorship.
Timeline
Claims Specialist/Stop Loss Coordinator
Vault Admin Services
04.2025 - Current
Member/Provider Advocacy Manager
Advanced Medical Pricing Solutions
09.2019 - 12.2024
Patient Accounts Payable/Receivable Specialist
AVP, Barnet Dulaney Perkins Eye Center
12.2017 - 09.2019
Resolution Supervisor
OptumRx
09.2014 - 12.2017
High School Diploma -
Teenage Parent Program