Summary
Overview
Work History
Education
Skills
Timeline
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LaSheryl McGuire

Red Oak,TX

Summary

A highly talented and eager individual seeking long term employment with a long standing company, with room for advancement within the company. I obtain, and maintain knowledge which empowers me to perform my job with great results. Strong written and verbal communication skills. I have the ability to prioritize and timely complete my workload while efficiently utilizing technology. Great decision making skills. I work well with others, and take initiative to work without supervision. I look forward to providing an excellent work ethic for your company, to ensure my direct supervisor and company are well represented. I am a dedicated worker, one who doesn’t shy away from hard work. Adapts well to new assignments or roles. My experience with Claims, Insurance, Benefits, will be an asset to your company. I look forward to working and growing with your company!

Overview

26
26
years of professional experience

Work History

Claims Associate: Auto Injury

State Farm Insurance
03.2024 - Current
  • Delivers a remarkable customer experience throughout the reporting and handling of complexity claims, identifying and ensuring prompt resolution of claims within scope of authority and segment criteria
  • Investigates, evaluates, and settles auto claims within the scope of Auto ILR to include verification of coverage, legal liability, and extent of property damage, which may require contact by telephone, email, correspondence, or other electronic media
  • Applies knowledge of policies procedures, laws, statutes, and insurance regulations when determining escalation criteria
  • Receives and processes claim information, and communicates with internal and external customers via phone and other communication channels
  • Works in a team environment to handle and investigate low complexity/high volume work in a call center environment
  • Complete all applicable training
  • Fulfill state licensing and continuing education requirements as applicable
  • Job may require travel overnight via commercial transportation or driving motor vehicles to any office locations where the Company does business, or other locations to conduct/attend training, conferences, meetings, and/or seminars
  • Follows established procedures to appropriately review, handle, and settle applicable routine property, and/or material damage claims
  • Assists Claim Specialist with handling and settling claims involving injury
  • Researches, resolves, and settles claims involving injury within approved limits and/or as directed
  • Processed insurance claims with accuracy and attention to detail.
  • Communicated with clients to gather necessary claim information.
  • Reviewed policy coverage to determine claim eligibility and compliance.
  • Collaborated with internal teams to expedite claim resolutions.
  • Utilized claims management software for tracking and documentation.
  • Assisted clients in understanding claims procedures and requirements.
  • Maintained organized records of all claims communications and decisions.
  • Provided training support to new associates on claims processes and tools.
  • Maintained accurate records of all claim processing activities in accordance with company policies and procedures.
  • Conducted research on claim issues, utilizing available resources such as databases and other documentation.
  • Interacted with clients via telephone, email, or in person to discuss claim status and provide updates.
  • Reviewed medical records and documents submitted by claimants to ensure accuracy and completeness of information provided.
  • Determined liability, compensability, and benefits due on each claim.
  • Updated existing processes and procedures as needed based on changes in industry standards or organizational needs.
  • Ensured compliance with applicable laws and regulations governing insurance industry practices.
  • Supported efficient handling of complex claims and followed up on open, denied, or suspended claims to complete required line items.
  • Processed payments for approved claims in a timely manner, adhering to established payment schedules and procedures.
  • Analyzed data and formulated decisions regarding the approval or denial of claims.
  • Collaborated with other departments within the organization to address multi-faceted problems that required interdepartmental solutions.
  • Performed quality control checks on completed claim files prior to submission for review by management personnel.
  • Tracked and reported on patterns of claims and repeat offenders to help eliminate system abuse.
  • Investigated potential fraudulent activities by reviewing claimant's past history of submissions, verifying identity, and obtaining additional evidence when necessary.
  • Adjusted and claims under close supervision of more experienced claims team members.
  • Delivered quality customer service to assigned, insured and claimants throughout entire claims lifecycle to promote service times.
  • Verified details with policyholders and requested additional information.
  • Coordinated with repair facilities and contractors to obtain repair estimates and ensure quality services.
  • Communicated effectively with policyholders, providing updates and explaining the claims process clearly.
  • Determined claim validity and assessed liability and damages to calculate appropriate compensation.

Optum

United Health Group
03.2023 - 02.2024
  • Posting insurance payments to patient’s accounts
  • Balancing Insurance checks
  • Account reconciliation
  • Provided detailed monthly account reports
  • Completed day-to-day duties accurately and efficiently.
  • Contributed innovative ideas and solutions to enhance team performance and outcomes.
  • Prioritized and organized tasks to efficiently accomplish service goals.
  • Collaborated closely with team members to achieve project objectives and meet deadlines.
  • Utilized various software and tools to streamline processes and optimize performance.

Medical Billing Analyst

Huron Consulting Group
04.2021 - 02.2023
  • Responsible for ensuring all claims are sent to clearing house without errors.
  • Correcting errors, disputing denials, timely filing reversals.
  • Review EOB’s to determine patient responsibility, payment posting, and collections experience.
  • Account Receivable experience.
  • Analyzed medical claims for accuracy and compliance with regulations.
  • Reviewed and resolved billing discrepancies to ensure timely payments.
  • Managed accounts receivable processes to optimize cash flow.
  • Collaborated with healthcare providers to clarify billing issues and inquiries.
  • Implemented process improvements to enhance billing efficiency and accuracy.
  • Trained new staff on billing procedures and software systems.
  • Generated detailed reports on billing metrics for management review.
  • Maintained up-to-date knowledge of industry changes affecting medical billing practices.
  • Collaborated with relevant parties to resolve billing issues, insurance claims, and patient payments.
  • Investigated denials or underpayments associated with claims submitted electronically or via paper forms.
  • Implemented corrective action plans when necessary in order to resolve any identified issues affecting claim processing times or accuracy rates.
  • Analyzed and processed medical insurance claims using ICD-10 codes to ensure accuracy in billing.
  • Reviewed patient records for completeness and accuracy of information, including coding and diagnosis.
  • Researched complex billing problems that arise during the course of filing claims.
  • Resolved discrepancies between providers, payers, and patients regarding billing issues.
  • Developed strategies to reduce denials and improve overall revenue cycle performance.
  • Ensured compliance with all Medicare and Medicaid rules and regulations pertaining to health care reimbursement policies.
  • Documented processes related to medical billing activities in order to improve efficiency within the department.
  • Collaborated with clinical staff on proper documentation requirements for successful reimbursement of services rendered.
  • Audited medical bills for coding errors and other discrepancies prior to submission.
  • Maintained up-to-date knowledge of current federal regulations concerning HIPAA compliance in regards to healthcare privacy laws.
  • Reconciled outstanding accounts receivable balances for timely collection of payments due from insurers or patients.
  • Participated in training sessions designed to stay abreast of changes in coding standards, regulations.

Internal Medicine – Claims Specialist - Billing Clerk

Health Texas Provider Network
Dallas, US
08.2015 - 01.2021
  • Company Overview: Baylor University Medical Center – BUMC
  • Timely input of demographic charges and time of service payment information.
  • Expert ability to add specific data such as modifiers, payer specific information, including authorization criteria, CPT and ICD-10 codes.
  • Input, review and prepare patient and insurance data.
  • Research and verify accuracy of billing data and revise any errors including adjustments and denials.
  • Knowledgeable to append modifiers based on payer specifics, insurance and authorization requirements.
  • Assist with training new employees on charge entry practices.
  • Understand and interpret the Correct Coding Initiative (CCI) as it applies to charge entry.
  • Reduce denials by correct use of modifiers, mapping, and linking codes with services.
  • Responsible for the processing and discrepancy reconciliation and closing of charge batches across all systems.
  • Ability to successfully track and follow up on information requests.
  • Work with groups to facilitate information and resolve charge questions.
  • Achieve goal of a 48-hour turnaround batch time.
  • Achieve goals set forth by management regarding error-free work, transactions, processes and compliance requirements.
  • Proactive resolution of issues and timely response to questions and concerns.
  • Clearly document issues and resolutions.
  • Deliver timely required reports to the management team; initiates and communicates the resolution of issues, such as inaccurate and/or incorrect charges.
  • Works to resolve encounter errors
  • Verify all compliance requirements are met
  • Identify possible discrepancies such as claim overpayments, underpayments, scanning issues, and other irregularities.
  • Baylor University Medical Center – BUMC
  • Reviewed and processed insurance claims for accuracy and compliance.
  • Communicated with healthcare providers to clarify claim details and requirements.
  • Investigated discrepancies in claims by gathering relevant documentation.
  • Collaborated with team members to streamline claims processing procedures.
  • Maintained detailed records of claims activities and communications.
  • Assisted in training new staff on claims management systems and protocols.
  • Resolved client inquiries regarding claim status and payment timelines.
  • Resolved claims by approving or denying documentation, calculating benefits due and determining compensation settlement.
  • Maintained detailed records of all claim activities including notes about conversations with claimants or representatives.
  • Maintained knowledge of policies and procedures and insurance coverage benefit levels, eligibility systems and verification processes.
  • Provided customer service by responding promptly to inquiries from claimants regarding their benefits or coverage.
  • Reviewed and analyzed insurance claims to determine validity, completeness, accuracy, and eligibility for payment.
  • Communicated with other departments to establish action plans and manage open claims to closure.
  • Processed payments for valid claims according to established procedures.
  • Investigated complex or high-value claims to identify discrepancies and fraud indicators.
  • Evaluated financial information provided by claimants in order to process payments quickly and accurately.
  • Conducted interviews with involved claims parties and witnesses to gather detailed information and arrange investigations.
  • Compiled data from multiple sources for reporting purposes.
  • Identified trends in rejected claims that could indicate system errors or fraudulent activity.
  • Performed periodic audits of closed files to ensure accuracy of documentation and compliance with regulations.
  • Assisted with filing appeals on denied claims with insurance companies.
  • Documented specific claims by completing and recording forms, reports and logs.
  • Researched medical records to evaluate claim validity and verify the existence of pre-existing conditions.
  • Facilitated communication between claimants, providers, attorneys, adjusters, employers, and other parties involved in a claim.
  • Performed quality assurance reviews on new hires' work product.
  • Resolved disputes between claimants and providers through negotiation.
  • Planned and conducted investigations of claims to confirm coverage and compensability.
  • Developed training materials for staff members on best practices for handling different types of claims.

Billing Specialists

D. King Consulting Inc.
04.2012 - 01.2015
  • I upload charges (billing) for various DR.’s that work within HCA Hospitals in Dallas, TX.
  • Constant correspondence with DR.’s in order to access the correct information needed to bill the patients accurately.
  • Ensure claims are billed accurately to submit to insurance companies.
  • Contact insurance companies in order to get payment made towards the patient’s accounts.
  • After insurance payments are made patients are billed for the remaining balance.
  • Receive & process payments over the phone made by patients using their credit cards, apply it to accurate accounts.
  • Submit monthly reports to management in order for the DR.’s to get paid.

Detention Service Officer

Dallas County Sheriff Department
Dallas, US
01.2002 - 05.2011
  • I maintain care, custody, and control of inmates housed in the Dallas County Jail.
  • I oversee inmates while they work in assigned jobs, I escort inmates away from their housing location when needed.
  • I observe the daily activities of inmates, and maintain institutional security for all inmates housed within Dallas Jails.
  • I document any incidents that may occur during the day, I keep a daily log to pass on vital information to the next officer.
  • I worked as the lobby officer, where I interacted with visitors, such as attorneys, parole & probation officers.
  • Directed individuals to the correct location with proper security measures, I operated radios, and directed calls to individuals using multi-line phones.
  • Skills obtained: Problem Solving, Communication Skills, multitasking, Multi-line Phone Systems

Insurance Company: Ledger Billing

United Healthcare (formerly Student Insurance Division)
01.2000 - 01.2002
  • I paid claims for students who received healthcare while at school.
  • I made detailed payments for students, and issued payments to colleges.

Education

High School or equivalent - General Studies

South Oak Cliff High SCHOOL
Dallas, TX

Skills

  • Medical billing
  • Medicare/Medicaid/Worker's Comp billing guidelines
  • Customer relationship management
  • Hospital/clinic setting
  • ICD-10
  • Insurance verification
  • EMR systems
  • Transcription
  • Medical office experience
  • CPT coding
  • Multi-line phone systems
  • Clerical experience
  • HIPAA
  • Medical records
  • Medical terminology
  • Epic
  • Meditech
  • HIS
  • PAS
  • Data Entry
  • ICD Coding
  • Anatomy Knowledge
  • Cerner
  • Phone Etiquette
  • Medical Coding
  • Excel
  • Word
  • Teams
  • Outlook

Timeline

Claims Associate: Auto Injury

State Farm Insurance
03.2024 - Current

Optum

United Health Group
03.2023 - 02.2024

Medical Billing Analyst

Huron Consulting Group
04.2021 - 02.2023

Internal Medicine – Claims Specialist - Billing Clerk

Health Texas Provider Network
08.2015 - 01.2021

Billing Specialists

D. King Consulting Inc.
04.2012 - 01.2015

Detention Service Officer

Dallas County Sheriff Department
01.2002 - 05.2011

Insurance Company: Ledger Billing

United Healthcare (formerly Student Insurance Division)
01.2000 - 01.2002

High School or equivalent - General Studies

South Oak Cliff High SCHOOL

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LaSheryl McGuire