Jayne Williams

• Demonstrated exceptional attention to detail while analyzing and managing 120 case files, consistently delivering outstanding customer service to providers, suppliers, and representatives
• Evaluated appeal submissions within assigned timeframe of 3-5 business days
• Collaborated with management team to ensure consistent and timely updates on ongoing reviews
• Investigated and resolved high volume of daily correspondence and emails pertaining to claims for rework, averaging 75-100 per day

• Maintained compliance with CMS guidelines while accurately adjudicating 150 Medicaid, Medicare, and Commercial claims
• Achieved high level of accuracy in calculating and processing payments for medical and hospital claims
• Ensured efficient management of 20-25 incoming correspondence and emails by actively identifying and addressing concerns raised by members or providers
• Verified authorization, medical benefits plan, explanation of benefits, deductibles, coinsurance, copay, coordination of benefits, stop loss, and out of pocket
• Achieved 100% commitment to quality by developing and executing proactive strategies for meeting individual and departmental production goals

• Identified root causes of accidents through thorough examination of evidence
• Evaluated 50 medical records and related paperwork of injured parties
• Monitored and documented progress and completion of cases through
comprehensive case log
• Adhered to necessary accident investigation laws, codes, and regulations

• Achieved perfect accuracy rate by accurately processing and resolving 250 medical claims, adjustments, and correspondence as per CMS guidelines
• Conducted comprehensive reviews of medical records to guarantee accuracy and completeness
• Implemented document management system to streamline organization of company files, resulting in readily available and current data
• Investigated and reported fraudulent claims

• Managed large workload by efficiently processing 150 medical and 50 hospital complex claims
• Achieved resolution of 1-5 claims discrepancies on daily basis by utilizing phone or written communication
• Sourced relevant supportive documents and medical data to evaluate eligibility for service reimbursement or rejection by analyzing CMS-1500's, UB92's within relational database system

• Reviewed documents for accuracy and completeness of 50 daily appeals prior to processing
• Streamlined appeal resolution process through efficient coordination and data gathering from multiple departments
• Utilized critical thinking skills to analyze and assess documentation, facts, laws, state, regulations, and organizational guidelines in order to make sound decisions
• Managed and documented all appeals process activities accurately