Jennifer Flores

Identified the issue with a claims error in regards to payment which could be due to contract update or eligibility update. There are also state updates that get implemented which also cause an adjustment or approved authorization from UM Dept. Reported overpayments and adjusted to correct underpayments. Submitted verification for the member's COB file to be verified and updated. Prior to new system update had to manually configure claims for Cost or Day outlier. Reviewed to sent for Partner Re to review for savings.

• Processed professional claims along with outpatient and inpatients claims. Processed from EDI reports given as well as reviewed TMHP manual to allow per state guidelines. Also in some instances had to submit out of state or out of network claims to the state for pricing. Submitted request to other departments to get information needed to process claim.

• Reviewed and processed commercial , Medicaid and Medicare claim appeals. Processed adjustment requests from provider services and customer service. Distributed daily workload to claims processors and adjustors