Jessica James

• Evaluated and processed claims to ensure compliance with company policies and regulations.
• Streamlined claims processing workflows, enhancing efficiency and reducing turnaround times.
• Participated in ongoing professional development opportunities to stay current with industry trends and best practices for claims advocacy.
• Created detailed reports on claim trends and common issues to inform companywide strategies for addressing recurring problems.
• Collaborated with various departments for efficient claims processing, resulting in quicker resolutions for clients.
• Managed medical records and sensitive patient data
• Managed a large caseload of claims, ensuring prompt attention to each case and maintaining organized records.
• Prepared insurance claim forms or related documents and reviewed for completeness.
• Carried out administrative tasks by communicating with various departments.

• Reviewed and adjudicated routine claims in accordance with claim processing guidelines.

• Analyzed and approved routine claims that could not be auto adjudicated.

• Applied medical necessity guidelines, determined coverage, completed eligibly verification, identified discrepancies and applied all cost containment measures to assist in the claim adjudication process.

• Routed and triaged complex claims to Senior Claim Benefits Specialist.

• Reviewed claim or referral submission to determine and apply appropriate guidelines, coding, member identification process, diagnosis and pre-coding requirements.

• Utilized all applicable system functions available ensuring accurate and timely claim processing services (i.e. utilizes claim check, reasonable and customary data, and other post-containment tools).

• Managed sensitive patient data, including medical records

• Accurately input patient and client data into internal filing program
• Provided clerical and administrative support to fulfillment department and various departments within company
• Adhered to company policies, guidelines and state/federal regulations pertaining to patient information
• Self-started and worked independently while completing various tasks in fast-paced environment
• Utilized professional and effective oral, written and interpersonal skills via face to face or telephone interaction
• Created and maintained spreadsheets to quickly identify and locate patient requests
• Maintained accurate records of all patient and client details

• Professionally handled behavioral-related patient and provider calls in high-volume call center
• Compassionately triaged crisis calls after performing proper screening protocols
• Reviewed and researched complex claim issues that require escalated projects
• Assisted with multiple internal departmental special projects such as, provider credentialing processing, provider account maintenance and auditing and member appeals

• Provided clerical and administrative support to provider service department by accurately maintaining and auditing files of provider credentialing status via multiple Office programs and office equipment
• As a Team Lead, assisted team members with identifying and resolving varying complex provider inquiries
• Communicated directly with top tier facilities and providers via telephone, email and fax regarding patient accounts, as well as provider data and credentialing and related questions
• Collaborated with internal and external partners and utilized basic knowledge of ICD-9, ICD-10, and HCPCS coding guidelines to research claims and appeals to determine eligibility for adjudication