EPIC Certified
Kimberly Claude
Senior Appeals And Claims Specialist
Windsor Mill,MD
Summary
Effective Medical Medicare/Medicaid Claims Processor with strong background building rapport with providers to discuss claim status or claim denials. Driven performer equipped to handle multiple administrative tasks effectively. Exemplary worker with highly investigative skills when processing claims.
Overview
9
9
years of professional experience
10
10
years of post-secondary education
3
3
Certifications
Work History
Customer Advocate II
CareFirst
01.2022 - Current
- Verified client information by analyzing existing evidence on file.
- Calculated adjustments, premiums and refunds.
- Reviewed provider coding information to report services and verify correctness.
- Paid or denied medical claims based upon established claims processing criteria.
- Used administrative guidelines as resource or to answer questions when processing medical claims.
- Maintained knowledge of benefits claim processing, claims principles, medical terminology, and procedures and HIPAA regulations.
- Managed large volume of medical claims on daily basis.
- Generated reports on medical claims processing activities and results.
- Monitored and updated claims status in claims processing system.
- Followed up on denied claims to verify timely patient payment and resolution.
- Identified and resolved discrepancies between patient information and claims data.
- Evaluated medical claims for accuracy and completeness and researched missing data.
- Assessed medical claims for compliance with regulations and corrected discrepancies.
- Verified patient insurance coverage and benefits for medical claims.
Patient Services Coordinator III
University of Maryland Medical Center
02.2020 - 12.2021
- Registration Process, Scheduling Process, Referrals, Pre-certification and Authorization Process, Oversees insurance validation process
- Acted as a resource for clinical information and direction for appropriate scheduling and registration
- Created new patients within the EPIC system
- Accurate Time-of-Service (TOS) payment processing
- Efficiently schedules, reschedules, and cancels patient appointments, procedures and exams.
- Telephoned and interviewed patients and family members to obtain pre-registration information and confirm appointments.
- Provided patient with after-visit summary and scheduled next appointment to maintain continuous care and facilitate treatment plan.
Patient Service Representative Sr. Team Leader
TriWest Healthcare Alliance
11.2018 - 02.2020
- Handled the scheduling needs for our Nation's Veterans in 7 States, building authorizations, processing claims and provider credentialing
- Expert in scheduling all medical categories of care, dental and mental health
- Handled all medical billing, claims and the scheduling needs for our Nation's Veterans in 7 States, building authorizations, processing claims and provider credentialing
- Medicare/Medicaid Billing as secondary
- Provide Pre-Auth Intake for Veterans admitted thru ER as well as Global Auths for Maternity
- Provided Auth status and pre-auth requirements
- Expert in scheduling all medical categories of care, dental and mental health
- Provided positive guidance, training, and monitoring of staff on the processes of patient scheduling functions, billing and claims processing
- Handled approximately 25-100 calls daily
- Highly motivated and results-focused with over ten years of experience as a Team Supervisor for 5-9 individuals
- Monitored telephone statistics daily and intervene as needed to meet standards.
- Entered patient demographic and insurance data into electronic medical record system.
- Resolved billing inquiries and disputes in timely fashion.
- Managed patient registration process, confirming data accuracy and completeness.
- Verified insurance eligibility and coverage for patients.
Insurance Specialist III
Delta Dental
07.2015 - 10.2018
- Heavy customer contact via inbound calls, email, chat and fax
- Handled all escalated calls for authorizations, claims and provider relations
- Responsible for maintaining current insurance practices, requirements, and forms; verifying proper reimbursement is received for services provided; processing and following up insurance claims; and documenting and coding information, interpreting medical records
- Reviewed patient accounts for resolution and determined appropriate billing distributions; processing statements and entering information into the database, and reviewing past due bills and following up on past due accounts.
- Processed eligibility and benefits verification and authorization requests.
- Resolved discrepancies in insurance payments by collaborating with carriers.
- Acted as subject matter expert, answering internal and external questions and inquiries.
- Utilized CRM software to manage client relationships.
Education
Master of Science - Nursing Administration
Tuskegee University
Tuskegee, AL 08.1982 - 05.1988
Bachelor of Science - Nursing
Tuskegee University
Tuskegee, AL 08.1982 - 05.1986
Skills
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Additional Information
Experience with the following Billing Systems: AthenaHealth, EPIC Certified, ChangeHealthcare, Dentrix, Navinet, NextGen, Kareo, CRM
Personal Information
Willing To Relocate: Anywhere
Certification
Healthcare Data Analysts
Software
FACETS
AthenaHealth
Timeline
Healthcare Data Analysts
12-2023
Lean Six Sigma Foundations
12-2023
Customer Service Leadership
12-2023
Customer Advocate II
CareFirst
01.2022 - Current
Patient Services Coordinator III
University of Maryland Medical Center
02.2020 - 12.2021
Patient Service Representative Sr. Team Leader
TriWest Healthcare Alliance
11.2018 - 02.2020
Insurance Specialist III
Delta Dental
07.2015 - 10.2018
Master of Science - Nursing Administration
Tuskegee University
08.1982 - 05.1988
Bachelor of Science - Nursing
Tuskegee University
08.1982 - 05.1986
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