KERI-JOE REYNOLDS
Dallas,TX
Summary
Meticulous Quality Control Analyst with 10+ years of experience in claims auditing, error identification, and process improvement. Exceptional knowledge of healthcare coding systems including CPT, HCPCS, ICD- 10, and DRG methodologies. Demonstrated expertise in interpreting provider contracts, fee schedules, and reimbursement guidelines while maintaining high accuracy standards. Strong communicator skilled at creating clear audit reports and identifying systemic issues. Combines excellent attention to detail with the ability to work independently in virtual environments to deliver consistent quality results. Proficient in EZ- Cap, Microsoft Office, and various claims processing systems.
Overview
8
8
years of professional experience
Work History
Quality Control Analyst
Fedcap
07.2022 - Current
- Audit complex and high-dollar healthcare claims to determine financial and risk accuracy according to provider contracts and coding guidelines
- Review written dispute requests from providers regarding denied or incorrect payments based on contractual arrangements
- Identify potential issues related to system configuration, benefits, eligibility, and authorizations affecting claims processing
- Create clear and accurate audit findings with detailed recommendations for claims examiners and management
- Conduct regular audits of system configuration for provider contracts and amendments to ensure accurate claims processing
- Perform retrospective auditing of paid claims on a quarterly basis, flagging overpaid claims for recovery
- Maintain detailed documentation of all audit activities and findings in compliance with departmental standards
Claims Auditor
Fedcap
01.2020 - 07.2022
- Reviewed processed claims to verify accuracy of coding, payment calculations, and contract compliance
- Evaluated claims processing against provider contracts and health plan requirements to ensure accuracy
- Participated in quality improvement meetings to address recurring claims processing errors
- Maintained detailed records of audit findings and error trends for reporting purposes
- Prepared comprehensive audit reports highlighting system issues and examiner errors
- Collaborated with claims department to implement corrective actions for identified issues
- Consistently met or exceeded quality standards and productivity metrics for claims auditing
Claims Adjuster
Instacart
05.2019 - 01.2020
- Processed healthcare claims according to established guidelines and provider contracts
- Applied accurate medical coding and reimbursement methodologies to ensure proper claim adjudication
- Reviewed claim documentation for completeness and accuracy prior to processing
- Maintained detailed records of processed claims and adjudication decisions
- Participated in training programs to enhance knowledge of medical coding and reimbursement systems
- Demonstrated ability to prioritize multiple claims while maintaining high accuracy standards
- Developed proficiency in virtual claims processing environments and communication platforms
Claims Processing Associate
Walgreens
06.2017 - 05.2019
- Assisted with processing basic healthcare claims while identifying potential errors or discrepancies
- Developed fundamental understanding of medical coding systems and reimbursement guidelines
- Resolved routine claims issues promptly to facilitate accurate payment processing
- Supported tracking and documentation of claims processing metrics and performance
- Maintained detailed records of claim submissions and processing outcomes
- Collaborated with team members to ensure consistent claims processing standards
- Demonstrated strong attention to detail and accuracy in all claims-related activities
Education
Bachelor of Arts - Criminal Justice
University of Hartford
West Hartford, CT05.2017
Skills
Claims Auditing: Provider Contract Review, High Dollar Claim Analysis, System Configuration Audit, Error Identification, Recovery Recommendations
Healthcare Payment System: Fee Schedule Analysis, Risk Pool Assessment, Contract Interpretation, Payment Dispute Resolution, Reimbursement Guidelines
Healthcare Expertise: Managed Care, Provider Contracts, Health Plan DOFRs, Medical Coding
Quality Control: Claims Auditing, Error Detection, Accuracy Verification, Process Improvement
Communication: Clear Audit Reports, Written Documentation, Provider Correspondence
Problem Solving: System Issue Identification, Error Trend Analysis, Procedural Improvements
Medical Coding: CPT/HCPCS Coding, ICD-10 Diagnosis Codes, RBRVS Methodology, DRG Analysis, Coding Regulations
Software Proficiency: EZ-Cap, McKesson Claim Check, Redbook, Microsoft Office Suite
Claims Tools: DRG Pricing Software, Fee Schedule Analysis Tools, Claims Processing Systems
Process Management: Audit Documentation, Retrospective Review, Payment Recovery Procedures
Accomplishments
- Consistently maintained 98% accuracy rate in claims auditing, identifying over $1.2M in potential claim recovery opportunities over a 3-year period
- Developed comprehensive audit methodology that improved error detection by 45% and reduced improper payments by 25%
- Implemented enhanced quality control process that reduced audit cycle time by 40% while increasing error identification by 30%
- Recognized for exceptional attention to detail with a 98% accuracy rating on complex high-dollar claims reviews
- Identified and documented recurring system configuration issues that led to resolution of 4 major claims processing errors, resulting in 20% efficiency improvement
Leadership & Campus Involvement
University of Hartford - Treasurer Residential Hall Association
Connecticut
08/2013- 05/2017
- Managed an annual student housing budget of over $10,000, ensuring compliance with university financial policies and accurate record-keeping
- Conducted regular internal audits of student organization expenditures to identify discrepancies, reduce waste, and improve budget forecasting
- Collaborated with executive board member and campus leadership to develop cost-control strategies and increase transparency
- Gained experience in auditing practices and financial documentation through student leadership, supporting accurate record-keeping and compliance tracking
Timeline
Quality Control Analyst
Fedcap
07.2022 - Current
Claims Auditor
Fedcap
01.2020 - 07.2022
Claims Adjuster
Instacart
05.2019 - 01.2020
Claims Processing Associate
Walgreens
06.2017 - 05.2019
Bachelor of Arts - Criminal Justice
University of Hartford
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