Jennifer Pottiger
Reading,PA
Summary
Results-driven Claims Adjuster Team Lead with expertise in claims adjudication, medical coding, and fraud detection. Proven ability to streamline operations and enhance team productivity, ensuring exceptional customer service and adherence to compliance standards.
Overview
40
40
years of professional experience
Work History
Claims Adjuster Team Lead
Loomis Company
Wyomissing, PA
05.2001 - Current
- Reviewed and adjudicated medical, dental, and vision claims according to plan documentation.
- Maintained workflow backlog to consistently meet production and service level standards.
- Evaluated technical claim referrals and appeals for accuracy and effectiveness.
- Managed incoming calls from policyholders, resolving inquiries and issues promptly.
- Provided training to adjusters on best practices and company procedures.
- Assisted in fraud detection by identifying suspicious claim activities.
- Facilitated interdepartmental communication to enhance collaboration among teams.
- Calculated and authorized payment of claims within designated authority level.
- Evaluated insurance claims for accuracy and completeness.
- Analyzed policy coverage and determined claim eligibility.
- Delegated daily tasks to optimize team productivity and ensure timely completion.
- Supervised medical claims staff and ensured compliance with company policies.
- Colaborated with healthcare providers to resolve claim discrepancies efficiently.
- Monitored workflow and addressed issues to maintain operational effectiveness.
- Facilitated communication between departments to streamline claims resolution processes.
- Conducted regular audits of submitted medical claims for accuracy before submitting them for payment consideration.
- Analyzed, reviewed, and processed complex medical insurance claims according to established policies and procedures.
- Communicated effectively with clients via phone calls or emails regarding any questions or concerns about their claim status.
- Supervised and monitored daily activities of the medical claims department staff to ensure accurate and timely processing of all claims.
- Trained new staff on medical claim processing systems, policies, and procedures.
- Provided guidance and support to team members regarding challenging claims or customer service inquiries.
- Performed quality assurance reviews on submitted claims to verify completeness and accuracy prior to submission.
- Identified potential areas where workflow improvements could be made within the department in order to increase productivity levels.
- Maintained up-to-date knowledge of coding changes, regulatory updates, payer requirements as they relate to the medical claims process.
- Stayed current on HIPAA regulations, benefits claims processing, medical terminology and other procedures.
- Evaluated pending claims to identify and resolve problems blocking auto-adjudication.
- Checked documentation for appropriate coding, catching errors and making revisions.
- Precisely calculated refunds, premiums, and adjustments.
- Retained strong medical terminology understanding in effort to better comprehend procedures.
Senior Medical Claims Examiner
Aetna/Us Healthcare
Reading and Allentown, Pennsylvania
10.1985 - 05.2000
- Processed large volumes of medical, dental, vision, and disability claims with high accuracy.
- Reviewed claim information to identify duplicate coverage and assess unusual fees.
- Analyzed claims for discrepancies ensuring compliance with company policies.
- Educated members and plan sponsors on available products and services.
- Prepare and present reports on claims activity and performance to upper management, to improve claims processes and policies.
- Conducted audits to verify adherence to regulatory requirements.
- Managed complex claims using internal systems, focusing on efficiency.
- Manage and support team of adjustors, providing guidance, and training, to ensure high quality claims processing.
- Processed appeals from providers regarding denied claims.
Education
Bachelor of Arts - Communications
Alvernia University
Reading, Pennsylvania, PASkills
- Claims adjudication and processing
- ICD9, ICD10, ADA coding and compliance
- Fraud detection strategies
- Customer relationship management
Timeline
Claims Adjuster Team Lead
Loomis Company
05.2001 - Current
Senior Medical Claims Examiner
Aetna/Us Healthcare
10.1985 - 05.2000
Bachelor of Arts - Communications
Alvernia University