Kristen Barnes
Bristol,CT
Summary
Experienced Medical Claims Analyst with an extensive background in processing healthcare insurance claims. Proficient in interpreting and applying medical coding for precise claim resolution. Possesses robust analytical abilities along with a thorough understanding of medical terminology, CPT, ICD-10 codes, and HCPCS. Proven track record of process optimization and efficiency improvement in previous positions.
Overview
25
25
years of professional experience
Work History
Medical Biller and Credentialing Specialist
Collaborative Medicine, LLC
Canton, CT
08.2022 - Current
- Processed and submitted insurance claims with precision for timely reimbursement.
- Reviewed medical records to ensure compliance with coding guidelines and regulations.
- Implemented workflow improvements that enhanced accuracy in claim submissions.
- Worked closely with physicians to accurately assign ICD-10 diagnostic codes for optimal reimbursement rates from insurance companies.
- Managed verification of provider credentials using industry-standard tools and databases.
- Collaborated with healthcare providers to resolve discrepancies in credentialing documentation.
- Conducted audits of provider files, ensuring all necessary documents were up-to-date and compliant with regulatory requirements.
- Enrolled providers and Medicaid, Medicare, and private insurance plans.
CLINICAL CLAIM REVIEW MEDICAL CLAIMS ANALYST
CVS HEALTH
02.2022 - Current
- Reviewed medical records and documents to determine coverage eligibility of claims for insurance benefits.
- Performed data entry into the computer system to record information regarding claim status.
- Analyzed and evaluated claim forms, medical reports, bills, and other documents to ensure accuracy of data.
- Researched discrepancies between submitted documentation and actual records to identify errors or omissions.
- Applied knowledge of coding systems such as CPT-4 and HCPCS codes for proper reimbursement.
- Evaluated the validity of assigned claims by verifying that services are medically necessary according to established guidelines.
- Documented decisions on each claim based on research findings and applicable benefit plans.
- Maintained accurate records of all processed claims in accordance with departmental requirements.
- Participated in meetings with internal stakeholders regarding changes in policy, procedure, technology.
- Updated job knowledge by participating in educational opportunities; reading professional publications; maintaining personal networks; participating in professional organizations.
SENIOR CLAIMS ANALYST
CIGNA HEALTHCARE
12.2001 - 02.2020
- Subject matter expert for correspondence stoploss team, escalated claims issue processor and certified adjunct facilitator.
- Supported claims adjustments, appeals and issues across a diverse portfolio of business units including Medicare (as both primary & secondary payer), pharmacy, mental health & substance abuse, medical, facility/inpatient, and outpatient.
- Proficient in coordination of benefits, subrogation, direct member reimbursements, high cost claimants, dedicated account processing, and late payment interest states processing.
- Supported deployments (including Sundays and Holidays) and remediated system issues to aid in claim efficiency and payment fidelity.
- Audited incoming trainees as well as trained new employees on process correspondence and best practices.
PHONES AND CLAIMS SPECIALIST
CIGNA HEALTHCARE
05.2001 - 12.2001
- Inbound telephonic support for claims questions/issues arising from Customers and Providers.
- Authorized to perform simple adjustments for Customer and Provider claims as necessary.
CLAIMS CUSTOMER SERVICE REPRESENTATIVE
CIGNA HEALTHCARE
06.2000 - 05.2001
- Provided high quality customer service via telephone and correspondence to address customer requests related to claims and policy issues.
- Researched issues identified discrepancies and remediated errors.
- Secured foundational knowledge of insurance coverages, commonly used insurance concepts, best practices, and operating procedures.
- Assigned 'special projects' to support the advancement of department objectives.
Education
Bachelor of Science - Health Science
Trident University
Cypress, CA10.2022
Certified Medical Billing and Coding Specialist - undefined
Trident University
02.2021
Microsoft Certified Professional - undefined
New Horizons Computer Learning Center
05.2001
High School Diploma - undefined
Bristol Central High School
06.1999
Skills
- Proficient in ICD, CPT, and HCPCS coding
- HIPAA compliance knowledge
- Quality evaluation procedures
- Analytical decision-making
- Data protection protocols
- Claim validity determination
- Organizational abilities
- Clinical language proficiency
- Document security protocols
- Document workflow
- Data Interpretation
- Interpersonal and written communication
- Familiarity with insurance policies
- Claims review
- Data privacy initiatives
- File and Record Management
Timeline
Medical Biller and Credentialing Specialist
Collaborative Medicine, LLC
08.2022 - Current
CLINICAL CLAIM REVIEW MEDICAL CLAIMS ANALYST
CVS HEALTH
02.2022 - Current
SENIOR CLAIMS ANALYST
CIGNA HEALTHCARE
12.2001 - 02.2020
PHONES AND CLAIMS SPECIALIST
CIGNA HEALTHCARE
05.2001 - 12.2001
CLAIMS CUSTOMER SERVICE REPRESENTATIVE
CIGNA HEALTHCARE
06.2000 - 05.2001
Certified Medical Billing and Coding Specialist - undefined
Trident University
Microsoft Certified Professional - undefined
New Horizons Computer Learning Center
High School Diploma - undefined
Bristol Central High School
Bachelor of Science - Health Science
Trident University