Jeuellise Mems
San Antonio,TX
Summary
Committed job seeker with a history of meeting company needs with consistent and organized practices. Skilled in working under pressure and adapting to new situations and challenges to best enhance the organizational brand.
Overview
8
8
years of professional experience
Work History
Medical Claims Examiner
WellMed Medical Management - United Health Group
San Antonio, TX
09.2022 - Current
- Analyzed provider contracts to ensure proper reimbursement levels were achieved.
- Reviewed and processed medical claims for accuracy and completeness according to established guidelines.
- Determined the appropriate payment amount based on contractual agreements with providers.
- Researched medical records to identify additional information needed for processing claims.
- Assessed coding accuracy, using ICD-10 codes, CPT codes, HCPCS codes, and modifiers.
- Ensured HIPAA compliance by maintaining strict confidentiality of patient information.
- Investigated discrepancies in claims data, reconciled errors, and corrected inaccuracies as needed.
- Maintained updated knowledge of changes in healthcare regulations impacting claims processing.
- Stayed current on HIPAA regulations, benefits claims processing, medical terminology and other procedures.
- Reviewed claims for accuracy before submitting for billing.
- Accurately processed large volume of medical claims every shift.
Member Health Assessor
Caresourse
01.2021 - Current
- Engaged members to gather information for effective delivery of care including behavioral health and long-term care
- Conducts Health Risk Appraisals (HRA) to assess members' medical history and ongoing wellness requirements
- Conducts telephonic education which empowers the member to manage and improve their health, wellness, safety, adaptation, and self-care through effective care coordination and case management
- Developed problem lists and individualized care goals in accordance with program protocols, utilizing members' stated needs and preferences.
- Uses web-based software system for documenting HRA’s, activities and education provided.
Utilization Management Coordinator
Wellmed
07.2016 - 01.2020
- Established effective communication channels with both providers and patients/members.
- Effectively utilized policy guidelines to review and process authorization requests
- Conducted utilization reviews for members to ensure services are medically necessary, appropriate and cost effective.
- Collaborated with providers and health plans to ensure quality of care and accuracy of claims processing.
- Analyzed medical records to assess whether requested services met criteria based on evidence-based guidelines.
- Handling Escalation calls
- Enters authorizations into data system to ensure timely review of and downstream claims processing
- Works closely with UM RN staff to escalate decisions that require clinical review and oversight
- Handles all authorization requests timely and accurately, adhering to performance measures
- Follows department and organizational policies and procedures as well as adheres to all applicable regulatory, contractual and compliance requirements
- Responded to health care providers' calls regarding authorizations and appeals
- Efficiently label and route incoming faxes for our team
- Achieved optimal training results by guiding and mentoring newly hired staff.
Education
Bachelor of Science - Psychology
SNHU
New Hampshire, OH04-2026
Medical Office/Billing and Coding Specialist -
First Institute
01.2009
General (Diploma) -
Community High School
01.2007
Skills
- Interpersonal abilities
- Documentation Review
- Medical Terminology
- Customer Service
- Data security procedures
- Organizational abilities
- Critical Decision-Making
- ASC Coding
- Insurance Verification
- Insurance Claims
- Insurance claims processing
- Meticulous recordkeeping
- Provider Relations
- HIPAA
- Telephone Etiquette
- Quality assurance checks
Accomplishments
- Property & Casualty Insurance License – 2009
- First Aid & CPR Certified – 2007
- Medical Auto Injector Certified – 2007
Timeline
Medical Claims Examiner
WellMed Medical Management - United Health Group
09.2022 - Current
Member Health Assessor
Caresourse
01.2021 - Current
Utilization Management Coordinator
Wellmed
07.2016 - 01.2020
Bachelor of Science - Psychology
SNHU
Medical Office/Billing and Coding Specialist -
First Institute
General (Diploma) -
Community High School