Jemeela Beharry-Bhagwan
Brooklyn,NY
Summary
Knowledgeable Examiner with five years of experience in the claims adjustment field. Strong knowledge of resolution procedures and experienced handling Provider's inquiries. Detailed, focused, organized and professional in stressful situations.
Overview
8
8
years of professional experience
Work History
Claims Pricing Examiner
Metro Plus Health Plan - Claims
- Process Outpatient/Inpatient claims for Medicaid, Gold Care, and Essential Plan line of business for all contracted and non-contracted facilities
- Evaluate, examine, and adjudicate claims pended by the system due to contractual and/or payment discrepancies by reviewing description of services on claims related to outpatient and /or inpatient claims
- Process high-level claims inquiries about performing claims adjustments to correct payment errors (overpayment/underpayment) associated with outpatient and/or inpatient claims
- Research provides inquiries regarding pricing discrepancies including recommending changes for system design, methods, procedures, policies, workflows, and contractual implementation
- Manage and ensure appropriate follow-up and closure of all inquiries
- Participation in the development, testing, and implementation of new and or revised system enhancements to ensure effective and efficient claims processing
- Ensure adherence to all Claims Processing legislative and regulatory requirements
- Participate in quality projects as required by management
- Perform other duties as assigned by the claims manager.
Claims Examiner
Metro Plus Health Plan - Claims
12.2016 - Current
- Data entry and adjudicated claims
- Update all member demographic changes
- Respond to all claim billing inquiries from providers
- Process and resolve complaints and record given information in the system.
- Claims review inquiries, handle provider and utilization management inquiries, etc
- Handle provider inquiries Conduct detailed bill review
- Report overpayments, underpayments, and other irregularities
- Review and analyze incoming fax from CSU; process & audit claims to ensure that adjusters have followed proper methods
- Present cases and participate in their discussion with Managers and core issues.
- Examine claims investigated by insurance adjusters, further investigating questionable claims to determine whether to authorize payments
- Verify and analyze data used in settling claims to ensure that claims are valid and that settlements are made according to company practices and procedures
- Adjust reserves and provide reserve recommendations to ensure reserving activities consistent with corporate policies
- Investigate, evaluate, and settle claims, applying technical knowledge and human relations skills to effect fair and prompt disposal of cases and to contribute to reduced loss ratio
- Pay and process claims within the designated authority level.
Claims Pricing Examiner II
Metro Plus Health Plan - Claims
- Current
- Conduct special projects/studies and participate in various work groups upon request.
- Provide guidance and resolution in the investigation and final disposition of complex claim matters from Senior Management, Customer Service, Network Relations, and other internal departments within MetroPlus
- Manage and ensure appropriate follow-up and closure of all inquiries
- Participation in the development, testing, and implementation of new and or revised system enhancements to ensure effective and efficient claims processing
- Process Outpatient/Inpatient claims for the Medicaid, GoldCare, and Essential Plan line of business for all contracted and non-contracted facilities
- Evaluate examine, and adjudicate claims pended by the system due to contractual and/or payment discrepancies by reviewing the description of services on claims related to outpatient and /or inpatient claims
- Process high-level claims inquiries in reference to performing claims adjustments to correct payment errors (overpayment/underpayment) associated to outpatient and/or inpatient claims
- Research provider's inquiries regarding pricing discrepancies including recommending changes for system design, methods, procedures, policies, workflows, and contractual implementation
- Participate in quality projects as required by management
- Perform other duties as assigned by the Clams Manager.
Clerical Associate
Metro Plus Health Plan - Claims
01.2016 - 12.2016
- Prepare and mail correspondence letters to Providers
- Daily receipt of all incoming department emails, referrals, and inquiries and batch accordingly
- Date stamping, sorting, and recording of all department mail, referrals, and inquiries
- Sort incoming correspondence from members and providers and forward mail to appropriate parties Ensure W-9 forms, live checks, and other documents received from providers are sent to Provider Relations in a timely manner
- Handle EOB and check requests ensuring that providers receive the information requested in a timely manner.
- Batch and Sort received Fax
- Separate faxes by individual claims such as W-9 attached, Exchange, Medicare, or Bulk claims
- Create Reports such as Inventory Reports (fax received, outstanding, and pending) Keeping Track of all outgoing and incoming faxes In charge of keeping records of incoming checks via mail or email Communicate and deliver checks to the Finance Department
- Sort and Batch Checks Prepare processed claims, checks, and letters for Scanning
- Responsible for storage of scanned documents and renaming documents in the system
- Copy necessary documents
- Update claims service logs daily using Excel spreadsheets.
Education
High school Diploma (Global Language) -
St. Mark Secondary School
St Mark, Grenada07.2000
Office Suite Diploma -
School For Higher Learning
St George, Grenada07.2001
Medical Billing & Coding Certified -
Manhattan Institute Allied Medical Training
Manhattan New York, New York09.2016
Skills
- Macess
- Power Stepp
- AWD
- Provider Contracting
- Epaces
- Webstrat
- 3M
- Faxcom
- Microsoft Word
- Excel
- PowerPoint
- Outlook
- Data Entry
- Adaptive team player
- Energetic work attitude
- Sharp problem solver
- Strong organizational skills
Timeline
Claims Examiner
Metro Plus Health Plan - Claims
12.2016 - Current
Clerical Associate
Metro Plus Health Plan - Claims
01.2016 - 12.2016
Claims Pricing Examiner
Metro Plus Health Plan - Claims
Claims Pricing Examiner II
Metro Plus Health Plan - Claims
- Current
High school Diploma (Global Language) -
St. Mark Secondary School
Office Suite Diploma -
School For Higher Learning
Medical Billing & Coding Certified -
Manhattan Institute Allied Medical Training
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