Jennifer L. Baker
Tampa,FL
Summary
Highly skilled Managed Care Operations professional with 18+ years' of expertise. Proficiency in Facets Core, NetworX Pricer 5.8 version, Claims, and Provider/Contract pricing. Extensive knowledge in Perot Claims Systems (Diamond, Xcelys, Peradigm), Cactus, and Salesforce. Experienced in testing, UAT, plan building, configuration, and contract pricing. Strong background in medical claims processing, analysis, and Front Desk/office patient intake. Additional skills in various systems/tools including ICD-9/ICD-10, Omni Flow, CAQH, CISWEB, and more. Seeking a challenging role in a Facets and NetworX-focused organization to drive success and contribute expertise to complex projects.
Overview
19
19
years of professional experience
Work History
Pricing Configuration/Claims Specialist
BCForward, Elevance Health
03.2023 - Current
- Process and adjust health claims in alignment with claims policies and procedures
- Handle complex claims with expert understanding of contract pricing, processing, policies, government regulations, coordination of benefits, and healthcare terminology
- Analyze and process claims related to events to determine the extent of company liabilities
- Conduct research and analysis to address claims issues, responding to inquiries and engaging with clients
- Demonstrate self-guided proficiency with various products (e.g., HMO, PPO, COB).
- Created and maintained version description documents and worked with version control library.
- Supported customers and government teams with accurate, timely information on infrastructure system and service configuration items.
- Communicated and explained business requirements to team members to understand and implement functional demands.
- Analyzed existing systems and databases and recommended enhancements to solve business needs
- Proven ability to develop and implement creative solutions to complex problems.
- Participated in team projects, demonstrating an ability to work collaboratively and effectively.
- Identified issues, analyzed information and provided solutions to problems.
Business Professional, Pediatric Dentistry
06.2021 - 01.2023
- Provide personal introductions and welcome patients/provider reps
- Educate patients on patient intake forms, confirming, updating, and verifying demographic and clinically necessary information
- Update patient insurance information and guide patients through the next steps, facilitating hand-offs to Dental Assistants or clinicians
- Monitor computer systems for daily patient appointment confirmations and insurance verifications
- Maintain a safe, clean, and professional reception area.
Extended Day Counselor
Trinity School for Children
08.2020 - 05.2021
- Support K-5 after-school care and provide daily snacks to children
- Assist children with homework and ensure classroom cleanliness
- Communicate behavioral notifications to parents.
Ideal Dentistry/Origami Orthodontics
10.2020 - 02.2021
- Assist the dentist during various treatment procedures
- Take impressions of patients' teeth for study casts (models of teeth)
- Educate patients on proper oral hygiene strategies and provide post-treatment care instructions
- Perform dental radiographs (x-rays) and intra-oral photos
- Assist in dental tray setup and cleanup.
Configuration Specialist
10.2018 - 09.2019
- Loaded professional contracts into the Diamond System through research and provider data load activities
- Resolved provider load issues according to established processes
- Loaded new providers based on approved Credentialing Committee Lists
- Coordinated member move requests and participated in special projects
- Assisted in updating payable procedure codes, price rules, and fee schedules
- Ensured proper documentation for all load processes.
WellCare HealthPlans
05.2005 - 09.2019
Configuration Data Specialist
06.2016 - 10.2018
- Conducted accurate and timely provider research and verification, including license status checks
- Responded to inquiries, interpreted policy provisions, and resolved provider load issues
- Loaded and maintained provider data while building positive relationships with business partners
- Assisted in special projects and maintained high-quality work and productivity expectations.
Provider Operations Coordinator
Provider Relations
04.2015 - 06.2016
- Field Reps to resolve claims and payment issues
- Performed root cause analyses of operational and health services issues
- Reviewed and processed incoming and outgoing paperwork, including credentialing applications and contract forms
- Provided office, project management, provider recruitment, and data analysis support.
Claims Auditor
United Health Care, Remote
01.2013 - 09.2014
- Conducted audits on contract loads via Facets systems to ensure adherence to quality measures and reporting standards
- Researched installation issues and developed customer-specific resolutions
- Analyzed data to perform data mining and trend claims adjudication outcomes
- Provided support to client management through research and analysis
- Worked independently, handling self-directed tasks and less structured, complex issues
- Served as a valuable resource to others within the organization.
Sr. Claims Processor
05.2005 - 05.2008
- Processed claims with various hold reasons and provided final determinations
- Handled adjustments related to projects or provider disputes and conducted timely follow-up provider call backs
- Acted as subject matter expert for claims department projects and collaborated on process improvements
- Researched complex claims issues, analyzed trends, and determined resolutions.
Education
Expanded Functions Dental Assistant (EFDA) Dental Radiation Safety OSHA HIPPA CPR Certified -
Concorde Career College
Tampa, FLundefined
Thomas Jefferson High School
Tampa, FLundefined
Dentistry/Origami Orthodontics
Tampa, FLSkills
- Technical Analysis
- Written Communication
- Interpersonal Communication
- Dependable and Responsible
- Critical Thinking
- MS Office
- Facets/Perot Systems Software Proficiency
- Problem-Solving
Timeline
Pricing Configuration/Claims Specialist
BCForward, Elevance Health
03.2023 - Current
Business Professional, Pediatric Dentistry
06.2021 - 01.2023
Ideal Dentistry/Origami Orthodontics
10.2020 - 02.2021
Extended Day Counselor
Trinity School for Children
08.2020 - 05.2021
Configuration Specialist
10.2018 - 09.2019
Configuration Data Specialist
06.2016 - 10.2018
Provider Operations Coordinator
Provider Relations
04.2015 - 06.2016
Claims Auditor
United Health Care, Remote
01.2013 - 09.2014
WellCare HealthPlans
05.2005 - 09.2019
Sr. Claims Processor
05.2005 - 05.2008
Expanded Functions Dental Assistant (EFDA) Dental Radiation Safety OSHA HIPPA CPR Certified -
Concorde Career College
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Thomas Jefferson High School
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Dentistry/Origami Orthodontics
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