Jennifer Bitsoih
Albuquerque,NM
Summary
Magellan Health 3+ years
- Experienced with overseeing appeals and grievances processes to ensure timely resolutions. Utilizes strong analytical skills to evaluate case details and implement effective solutions. Knowledge of regulatory requirements and exceptional communication skills.
Conduent State Healthcare 5+ years
- Claims/Mailroom Manager 7 years
- Claims Mailroom Supervisor 3 years - Managed 10-12 employees
- Mass Adjuster - 2 years - Researched and adjusted medical claims
United Healthcare 16 years
- Claims Auditor 7 years - Audited medical claims for processing accuracy
- Adjustment Specialist 4 years - Adjusted claims for correct processing, created overpayments and underpayments, sent letters for claims that were overpaid to request a refund.
- Claims Processor 3 years - Processed and paid both Medical Professional and Facility claims
- Customer Service 2 years - handled incoming calls from Members and Providers of Service.
Overview
29
29
years of professional experience
Work History
Senior Appeals and Grievances Coordinator
Magellan Health
Albuquerque, NM
03.2023 - Current
- Coordinated appeals resolution processes to ensure compliance with regulatory standards.
- Analyzed grievances data to identify trends and recommend process improvements.
- Processed and finalized appeals and grievances within agreed-upon turnaround time.
- Remained knowledgeable regarding company policies and procedures and current developments within operational departments.
- Provided outreach for additional information for appeals and grievances.
- Maintained strict confidentiality of sensitive member information while adhering to HIPAA regulations during case investigations.
- Provided exceptional customer service when interacting with individuals involved in each appeal or grievance situation, demonstrating empathy and professionalism at all times.
- Submitted verbal and written notification to members and providers.
- Served as a key resource for colleagues seeking guidance on case-specific issues or regulatory requirements.
Claims & Mailroom Manager
Conduent State Healthcare / NM State Medicaid
Albuquerque, NM
03.2016 - 03.2023
- Coordinated with cross-functional teams to streamline communication and document flow.
- Led cross-functional teams to enhance operational efficiency and streamline workflows.
- Oversaw project timelines, ensuring alignment with organizational goals and expectation.
- Cultivated relationships with State Representatives to support strategic business objectives and initiatives.
- Accomplished multiple tasks within established timeframes.
- Enhanced customer satisfaction by resolving disputes promptly, maintaining open lines of communication, and ensuring high-quality service delivery.
- Cross-trained existing employees to maximize team agility and performance.
- Collaborated effectively with state representatives, management, and cross-functional departments to coordinate initiatives, resolve issues, and ensure efficient communication and successful outcomes.
Claims & Mailroom Supervisor
Conduent State Healthcare / NM State Medicaid
Albuquerque, NM
11.2015 - 03.2016
- Managed 10 employees
- Worked with other departments to better processes and resolve any issues.
- Worked with the management team to implement the proper division of responsibilities.
- Filled in areas that were short employees to meet any deadlines.
- Cross trained the department to cover the different areas within the department.
- Managed wide variety of customer service and administrative tasks to resolve customer issues quickly and efficiently.
- Immediately addressed issues with the Claims and Mailroom group so that they could be successfully resolved.
- Worked with the State and Managment to ensure that our deadlines were met.
- Pulled and Created reports for Management, the State and the department.
- Recognized and rewarded my group for any outstanding work performance by having luncheons and prizes and awards.
- Communicated clear expectations and goals to each team member.
Mass Adjuster
Conduent State Healthcare
Albuquerque, NM
03.2013 - 11.2015
- Handled State memos for special file adjustments
- Researched client files
- Adjusted claims for NM State Medicaid
- Sorted and Coded incoming mail
- Scanned claims and incoming correspondence for the different departments
- Filed provider and member documents
- Trained new mailroom employees
- Assisted Mailroom with opening, sorting, coding incoming correspondence
Claims Auditor
United Healthcare
Albuquerque, NM
01.2004 - 02.2013
- Researched issues related to claims processing to identify their origin and implement corrective solutions.
- Pulled reports of claims processed within each department.
- Reseached each claim to ensure payment or denial accuracy.
- Provided research findings report to Mangement
- Corrected any claims processing errors
- Communicated with the Providers of Service of any corrections made
- Attended weekly department meetings and provided any trends in errors.
- Reviewed insurance claims and member eligibility to determine overpayment trends and noncompliance issues.
Adjustment Specialist
United Healthcare
03.2000 - 01.2004
- Precisely completed appropriate claims paperwork, documentation and system entry.
- Carefully reviewed medical records for accuracy and completion as required by insurance companies.
- Appropriately and correctly identified errors in a claims processing.
- Identified and resolved patient/ physician billing and payment issues.
- Submitted refund requests for the claims paid in error.
- Worked with Systems Analysts to better the Smart Auditing System.
- Actively maintained current working knowledge of CPT and ICD-9 coding principals, government regulation, protocols and third party requirements regarding billing.
- Efficiently performed insurance verification and pre-certification functions.
- Examined diagnosis codes for accuracy, completeness, specificity and appropriateness according to services rendered.
- Researched CPT and ICD-9 coding discrepancies for compliance and reimbursement accuracy.
Customer Service Representative
United Healthcare
Albuquerque, NM
09.1999 - 03.2000
- Adeptly managed a multi-line phone system and answered incoming calls from a Member or Provider of Service.
- Explained claims processing to the caller.
- Claims that's were processed incorrectly, I sent a request to have the claim(s) adjusted and reprocessed.
- Verified patient's eligibility and claims status with insurance agencies.
- Diligently filed and followed up on third party claims.
- Handled call backs.
- Maintained strict patient and physician confidentiality.
Claims Processor
United Healthcare
Albuquerque, NM
06.1997 - 09.1999
- Research electronic/paper claims documentation for timely filing.
- Processed and paid incoming physician/facility billing.
- Precisely completed appropriate claims paperwork, documentation and system entry.
- Examined patients coverage, deductible, possible insurance carriers payments and remaining balance, not covered under policies when applicable.
- Remained up-to-date with all insurance requirements, including the details of patients financial responsibilities, fee-for-service and managed care plan.
Education
High School Diploma
Del Norte High School
Albuquerque, New Mexico1992
Skills
- Proficient in Microsoft Word, Excel, Publisher
- Knowledgeable with insurance benefits
- Strong attention to detail
- Customer Service
- Knowledge of HMOs, Medicare, Medicaid, PPO, IND and POS plans
- Hospital inpatient and outpatient records
- Familiar with commercial and private insurance
- HCPCS, CPT, Revenue ICD-9 codes
- UNET, FACETS, OMICAID PPCPROD claims systems
- JIVA record system
- Beacon and Siebel health systems
- Lotus Notes, Office Communicator, Outlook
- Workflow Systems
- Data entry
- 10 key
- Document scanning, editing, proofing, routing
- 65 WPM
- Strong organization skills
- Familiar with Indian Health Services (IHS)
- Proficient in UB and HCFA-1500 claim billing and forms
Timeline
Senior Appeals and Grievances Coordinator
Magellan Health
03.2023 - Current
Claims & Mailroom Manager
Conduent State Healthcare / NM State Medicaid
03.2016 - 03.2023
Claims & Mailroom Supervisor
Conduent State Healthcare / NM State Medicaid
11.2015 - 03.2016
Mass Adjuster
Conduent State Healthcare
03.2013 - 11.2015
Claims Auditor
United Healthcare
01.2004 - 02.2013
Adjustment Specialist
United Healthcare
03.2000 - 01.2004
Customer Service Representative
United Healthcare
09.1999 - 03.2000
Claims Processor
United Healthcare
06.1997 - 09.1999
High School Diploma
Del Norte High School