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Kristina McGuffin
Louisville,KY
Summary
Claims professional With over 20 years of experience in healthcare administration, claims processing, and customer service, demonstrated proficiency in Medicaid, Medicare, and specialty pharmacy authorization. Skilled in scheduling appointments, verifying benefits, and reviewing claims for accuracy. Expertise in coordinating peer-to-peer reviews, setting up authorizations, and handling appeals. Trusted to ensure timely resolution of provider and member inquiries, contributing to efficient operations and high-quality service delivery.
Overview
20
20
years of professional experience
Work History
CSR Rep for Express Scripts home Delivery
- Worked briefly to assist with answering phone when there was an overflow of calls
- Helped customers with Delivery issues and assisted with payments
Patient Care Advocates
- Accessing faxes through the system called Doc Manager in the Intake and Case Management Queue
- Making sure faxes were done with in a two hour period
- Entering all patient Demographic into the System called Casi
- Answering provider calls with in 30 seconds
- Assisted providers with setting up speciality pharmacy authorizations using the Express Path System
- Assisted Setting up Calls between Doctors for peer to peer reviews of the speciality pharmacy authorizations
UM Administration Coordinator 2
Humana
03.2022 - Current
- Customer Service
- Answer questions from providers about P2P appointments
- Scheduled P2P appointments for MD and the providers
- Helped our IP and OP teams with setting up auths
- Verify Members are Active with in the KY Medicaid network
- Review Claims for supporting Documents to ensure payments are correct
- Set up Auth for members when needed for SHA, EED, Home health, DME and other services provided
- Review Appeals and approve or deny based upon Criteria that is set up with in the State Medicaid Network for OH, OK, IN, KY, LA, VA, SC and FL
- Reviewed Medicaid claims across 8 states, ensuring compliance and accuracy, which improved processing efficiency within 12 months.
- Set up routes for MD to review disputes with in the CGX system
- Proficient in the systems of CGX, EHUB, CAS, Macess, CRM
- Maintained an average audit score of 98% over 12 months by enhancing documentation practices and conducting regular team training sessions.
Case Line Worker
GE Appliances
07.2021 - 03.2022
- Worked on the Case Line installing different parts to the GE refrigerator 4 door model
CSB Medicare W@H
Cigna
08.2020 - 07.2021
- Answering phones in a timely manner
- Helping customers understand their Medicare Supplemental coverage
- Verification of Benefits
- Answering calls from customers and provider
- Answering calls on claims
- Explaining all correspondence that are sent out
- Updating customer information
- Used the medicare website to help customers find answers to questions about providers and covered services
- Used a system called Lifepro to access customer's info, claims and benefits
- Used the phone system Finesse for logging in and out of calls
- Used Onbase to set up service request and checking customer's correspondence
- Canceled policies according to Medicare guidelines per state
- Canceled policies for customer's families after a death
- Adhere to all Medicare and company Guidelines
Claims Specialist
Express Scripts
Louisville, KY
12.2007 - 08.2020
- Worked claims for speciality Pharmacy drugs for ins plans 1199 and UHA
- Answered phone calls for all ins companies including Anthem, BGFH, 1199, UHA
- Posting payments that included but not limited to Deductible, Co-Ins, and approved payments
- Filing Checks and all claims with in customer chart
- Filling all claims that came into the claims department Data Entry
- Started to learn how to process humana claims when they were our client
Clinical Administrative Support
SHPS
Louisville, KY
06.2006 - 05.2007
- Answering a multi line phone
- Assisting Home Health providers to set up cases for Home Health Nurses using Maz MC program
- Setting up cases from faxes using LaserFiche
- Making sure all Daily Activity reports were sent out to the providers letting them know what was approved or not approved through KYHealth Choices
- Also set up faxes for Durable Medical Equipment as well as EPSDT
Temp for SHPS in the Flexible Spending Account Department
Today's Staffing
Louisville, KY
11.2005 - 06.2006
- Helped Federal Employees during Open Enrollment for their FSA
- Worked as a temp to hire in the claims department
- Worked as a temp in the KY Medicare part D
- Worked in setting up new cases for the Nurses
Education
Journalism Major - undefined
Jefferson Community College
01.2000
Journalism Major - undefined
Western Kentucky University
01.1999
High School Diploma - undefined
South Oldham High school
Crestwood, KY06.1997
Skills
Proficient in Microsoft system, Proficient Typing
Proficient in Medical systems such as CGX, EHUB, CAS, and Macess
Proficient in other Medical systems such as Citrix
Proficient in systems such as Verint and Workday for timekeeping
PUBLICATIONS
- Published chapter in Woman of Courage Vol 4
- Published chapter in Woman of Courage Vol 5
Accomplishments
I am a published author in two different novels!
Woman of courage Volume 4 and 5.
Timeline
UM Administration Coordinator 2
Humana
03.2022 - Current
Case Line Worker
GE Appliances
07.2021 - 03.2022
CSB Medicare W@H
Cigna
08.2020 - 07.2021
Claims Specialist
Express Scripts
12.2007 - 08.2020
Clinical Administrative Support
SHPS
06.2006 - 05.2007
Temp for SHPS in the Flexible Spending Account Department
Today's Staffing
11.2005 - 06.2006
CSR Rep for Express Scripts home Delivery
Patient Care Advocates
Journalism Major - undefined
Jefferson Community College
Journalism Major - undefined
Western Kentucky University
High School Diploma - undefined
South Oldham High school