Kaci Cluck
Benton,IL
Summary
I am a skilled Payment Accuracy Specialist with a good track record of delivering high-dollar results and supporting Cotiviti’s goals. My background includes two years at WPS Health Solutions in Veterans Claims, where I was promoted to Unit Coordinator within six months because I picked up the systems quickly and was always the go-to person for helping coworkers with their issues. That experience gave me a deep understanding of claims processing and policy, along with real experience being a direct contact between staff and management. I work well with a team but am also dependable when working on my own. I’m focused on being reliable, accountable, staying adaptable to changing needs, and finding the best ways to get successful outcomes. I am looking to build a long-term career within the company and am eager to take the next step by taking on more responsibility and contributing to Cotiviti’s success for years to come.
Overview
11
11
years of professional experience
Work History
Payment Accuracy Specialist
Cotiviti
08.2022 - Current
- Analyze claims data to identify trends, overpayments, and recovery opportunities.
- Collaborate with team members to streamline processes and improve operational efficiency.
- Update training materials to support direct reports and team growth.
- Knowledge shares during Team Meetings for OneNote, Excel, and Snagit to help and give some tips and tricks.
- Conduct regular workflow reviews to identify improvements and ensure Im working as efficiently as I can.
- Ensuring I maintain a low void rate and quality score while maintaining my workload and getting my claims worked timely.
- Expanding skillset through current training in bulk file processing.
- Always willing to help anywhere in anyway I can.
CLAIMS REPRESENTATIVE I
WISCONSIN PHYSICIANS SERVICES
03.2022 - 06.2022
- Process all Military and Veterans Health (MVH) claims from receipt through resolution in accordance with MVH regulations, guidelines, and quality standards, with expertise in coordination of benefits (COB), eligibility, and claims development. Process all claim types by determining corrective action to be taken on various types of errors pended by system and resolving interactive edits.
- Adjudicated diverse specialty claims such as pharmacy, ambulatory surgery, skilled nursing, and dental, ensuring compliance with regulations and efficient resolution.
- Analyze claims to determine if eligibility requirements and claim filing requirements are met and make determinations.
- Drafted correspondence to providers and beneficiaries to obtain missing claim information, facilitating claim processing.
- Identified cases requiring referral to other departments based on established guidelines.
VA MEDICAL CLAIMS UNIT COORDINATOR
WISCONSIN PHYSICIANS SERVICES
08.2019 - 07.2021
- Assisted department supervisors and analysts with unit workflow, reporting, complex cases, training, and follow-up to provide quality claims outcomes.
- Assisted supervisor in monitoring, distributing, and coordinating work within unit to ensure timely completion of tasks per contractual obligations.
- Ensure timely processing of tasks by loading and monitoring automated work queues.
- Provide direction, training, and instruction to all staff on application of new guidelines or procedures.
- Researched and resolved complex claims by analyzing highlighted issues and implementing appropriate solutions.
- Recommended and drafted clear updates to guidelines, procedures, and work instructions for improved clarity and compliance.
- Assist in implementing any new program or process changes.
- Assist with the creation, maintenance and updating of training materials as requested.
- Assist in training and orientation of new resources as requested.
- Research and work special assigned or complicated claims. Analyze and interpret highlighted issues to resolve unusual or difficult claim problems.
MEDICAL CLAIMS PROCESSOR
WISCONSIN PHYSICIANS SERVICES
02.2019 - 08.2019
- Review and process medical review claims in accordance with MVH regulations, claims processing guidelines, and Medical Review procedures.
- Reviewed and determined benefit payment levels, ensuring compliance with MVH regulations and claims processing guidelines.
- Analyzed claims to establish accurate pricing amounts, contributing to correct benefit disbursements.
- Initiated correspondence and requested documentation from providers to gather necessary information, facilitating timely claim resolution.
- Process non-medical specialty claims (physical, occupational and speech therapy, and dental) that suspend for medical review, assigning correct diagnosis and/or procedure codes.
Scheduling Manager
McDonald's
02.2015 - 11.2018
- Developed management skills at McDonald's by creating, editing, and rearranging weekly schedules. Managed floor operations, ensured adequate staffing at each station, and coordinated replacements for call-ins and no-shows. Progressed from crew member to management, consistently stepped in to cover shifts and maintain coverage.
- Developed COVID processing guidelines by researching claim processing rules and identifying relevant procedure and diagnosis codes.
- Coordinated staff schedules to align with peak service hours and customer demand.
- Managed inventory levels to ensure optimal stock for all restaurant operations.
- Oversaw training sessions for new employees on scheduling systems and procedures.
Education
High School Diploma -
Benton Consolidated High School
Benton, IL05-2011
Some College (No Degree) - Nursing
Rend Lake College
Ina, ILSkills
- Claims review
- Problem solving
- Team collaboration
- Documentation
- Skilled in Microsoft Office tools
- Strong proficiency in Excel functions
- Work Instruction Development
- Technical troubleshooting
- Problem solving
- Accountability
- Multi-tasking
- Consistent reliability
- Continuous improvement
- Trustworthy Execution
Timeline
Payment Accuracy Specialist
Cotiviti
08.2022 - Current
CLAIMS REPRESENTATIVE I
WISCONSIN PHYSICIANS SERVICES
03.2022 - 06.2022
VA MEDICAL CLAIMS UNIT COORDINATOR
WISCONSIN PHYSICIANS SERVICES
08.2019 - 07.2021
MEDICAL CLAIMS PROCESSOR
WISCONSIN PHYSICIANS SERVICES
02.2019 - 08.2019
Scheduling Manager
McDonald's
02.2015 - 11.2018
Some College (No Degree) - Nursing
Rend Lake College
High School Diploma -
Benton Consolidated High School
Communication Skills
- Created, taught, and implemented COVID rules and instructions starting in March of 2020.
- Responsible for looking up all COVID claim processing rules, identifying procedure codes, diagnosis codes, and places of service.
- Created work instructions for COVID claims and taught multiple classes on how to process them.
Education
other
References
- Tyler Borth, (715) 573-7210, Medical Claims Processing Supervisor
- Brianna Knutson, (715) 437-0452, Medical Claims Unit Coordinator Supervisor
- Laney Schreiber, (715) 432-3531, Medical Claims Unit Coordinator Supervisor
- Sarah Thomas, (630) 514-9877, MVH East Manager
- Breanna Carias, (618) 663-2837, Cotivity Policy Design Specialist
- Jamie Horn, (618) 713-0590, Current Cotivity Employee
- Kathleen Eckols, (618) 727-3351, Cotivity Audit Support Assistant
- Starla Barton, (618) 922-3481, Medical Claims Processing Supervisor
- Rose Akin, (618) 927-9534, McDonald's General Manager