Jenika McKinnie
Sanford,NC
Summary
Results-oriented professional with 7 years of extensive experience in the health insurance industry, specializing in claim adjustment, SIU recovery resolutions, and SIU prepay investigation. Proven track record of delivering accurate and efficient claim resolutions while maximizing cost recovery and mitigating fraud risks. Strong analytical and problem-solving abilities combined with excellent interpersonal and communication skills. A dedicated team player with a commitment to delivering exceptional customer service and achieving organizational goals. Previous experience in marketing and brand management with more than 8 years of experience in developing and implementing strategic marketing plans that resulted in increased sales for consumer goods.
Overview
17
17
years of professional experience
Work History
Special Investigative Unit Prepay Investigator
Optum Services
01.2021 - Current
- Responsibilities include reviewing existing procedures to ensure accuracy against current practices, synthesize current data to produce reports, triaging cases for clinical review, and interviewing members to gather information pertinent to healthcare fraud and/or abuse
- Identify abnormal billing trends through data collection methods along with aberrant billing pattern analytics and use the information to implement and manage provider centric SIU flags in pre-payment stage of claim processing
- Examine medical records and verify authenticity of documents compared to services billed
- Conduct policy member interviews to verify services for claims summitted on their behalf
- Collaborate with coding consultants and post-pay personnel to facilitate case resolution and conduct root cause analysis of claims and/or case processing, resulting in a 20% decrease in cases of fraud and abuse
- Independently managed multiple claims applications and over a dozen internal and external applications, resulting in streamlined research processes and more efficient decision-making
- Successfully completed special projects assigned by management, demonstrating flexibility and adaptability to changing priorities and requirements.
Senior Recovery Resolutions Representative
Optum
06.2019 - 01.2021
- Responsible for analyzing and resolving complex insurance claim cases, including the identification and recovery of overpayments, coordinating with various departments and stakeholders, and ensuring compliance with regulations and company policies
- Implemented data-driven approaches to identify trends and patterns in overpayment cases, resulting in a 10% improvement in detection accuracy and increased recovery rates
- Conducted in-depth analysis of complex insurance claims, identifying overpayments, and recovering erroneous payments
- Assisted in the development and enhancement of recovery resolutions tools, increasing automation and streamlining processes, resulting in a 25% reduction in manual effort
- Attended NCHAA fraud presentations enhancing expertise and credibility in fraud detection and investigation.
Associate Claims Representative
United Healthcare
07.2016 - 06.2019
- After serving 2 years in role was promoted to a subject matter expert
- Responsibilities for role included pre-adjudication audits for high dollar claims, facilitating team huddles, and responding to questions submitted to the SharePoint from claims representatives
- Reduced claim processing time by 20% through the implementation of streamlined workflows and process improvements, resulting in improved personal efficiency
- Communicated with internal and external business partners to identify and resolve complex or multi-issue inquiries, resulting in improved stakeholder relationships
- Spearheaded a process improvement, implementing a review procedure, reducing inappropriate redirects to Medical Claim Review team by 80%
- Processed and resolved an average of 50 claims per day with an accuracy rate of 100%, ensuring timely claim adjudication and customer satisfaction.
Marketing and Brand Manager
BGA Wholesale
Pembroke, Bermuda
06.2007 - 06.2014
- Increased brand awareness by developing and executing targeted marketing campaigns.
- Led rebranding initiatives, ensuring a consistent and impactful brand identity across all touchpoints.
- Boosted sales performance through the creation of compelling promotional materials and advertisements.
- Conducted thorough market research to identify emerging trends, informing future marketing strategies and product development direction.
- Collaborated with sales teams to create effective sales collateral that clearly communicated unique selling points of company offerings.
- Managed budgets effectively for numerous marketing projects without compromising on quality or desired results.
Education
Bachelor of Fine Arts in Graphic Design/Fine Arts -
The Art Institute of Atlanta
Skills
- Detailed report writing
- Research abilities
- Due diligence
- Risk Analysis
- Creative Direction
- Marketing Analytics
- Media Planning
- CRM Management
- Campaign Management
- Advertising Management
- Sales strategy
- Social Media Strategy
- Staff Coaching
- B2B Sales
- Brand positioning
- Product Management
- Marketing expertise
Timeline
Special Investigative Unit Prepay Investigator
Optum Services
01.2021 - Current
Senior Recovery Resolutions Representative
Optum
06.2019 - 01.2021
Associate Claims Representative
United Healthcare
07.2016 - 06.2019
Marketing and Brand Manager
BGA Wholesale
06.2007 - 06.2014
Bachelor of Fine Arts in Graphic Design/Fine Arts -
The Art Institute of Atlanta