Latoya Martin
Columbus,OH
Summary
Stop-loss Coordinator with over 18 years of experience in healthcare administration and claims processing, recognized for a collaborative approach and expertise in policy analysis. Proficient in documentation and process improvement, with a strong understanding of the medical stop-loss market. Dedicated to fostering team leadership and enhancing customer service to achieve efficient claims adjudication and optimal results.
Overview
18
18
years of professional experience
Work History
Customer Service Representative
TRC/ Job and Family Services
12.2024 - Current
- Great applicants, recipients and visitors to create a positive first impression and direct them to the appropriate department
- Collect and verify customer documents, uploading them to the correct case
- Provide administrative and clerical support to caseworks by addressing general inquiries and ensuring a smooth workflow
- Address routine question regarding case status, benefits issuance, and other related concerns, ensuring accurate information is provided
Front Office Assistant
First Step Recovery
10.2024 - 12.2024
- Greet all visitors and clients professionally, providing a positive first impression
- Answer phone calls promptly and direct inquiries to the appropriate staff members
- Schedule and manage client appointments, ensuring accurate record-keeping
- Check-in and check-out clients, verifying identification and following facility procedures
- Provide basic information about the recovery program and services offered
- Address client concerns and direct them to appropriate staff members when necessary
- Offer emotional support and maintain a positive and supportive environment for clients.
Stop-loss Coordinator
Consociate Health - NTT Data(Contracted)
01.2024 - 05.2024
- Responsible for personal SL Tracking for 78 groups adding 50% or spec claimants to the list along with adding check run dates daily - This is used for filing
- Coordinated Advanced Funding Requests with clients and Stop Loss Carriers along with releasing of checks
- Prepare and file spec claims to carrier for stop-loss reimbursement
- Follow up with carrier for status of reimbursement or partial payments/denials
- May have to do additional research to determine claimants or groups eligibility
- Posting financial transaction into accounting system
- Strong understanding of the medical stop-loss market
Stop-loss Coordinator
Healthscope Benefits - UMR/United Healthcare
08.2018 - 04.2023
- Responsible for filing initial and subsequent stop-loss claims timely to the carrier
- Advise Claims dept on advance funding and/or release of claim
- Run, format, and review reports manually for claims submission
- Review EOR’s for denials and claim reimbursements along with posting checks
- Year end review for assigned groups for potential overpayments/adjustments
- Develops and maintains a working relationship with carriers and their filing requirements
- Analyze policies against the quote, application, and plan document for accuracy and agreement.
- Support the renewal process through assistance with stop loss binding, disclosure and coordination/completion of all documents required for implementation of stop loss
- Communicate with broker/agent to obtain missing and additional documentation
- Audit and reconcile data between sources
- Trained new employees on stop-loss policies and procedures
Claims Examiner III
Accountable Health Care - ATI
11.2012 - 12.2017
- Handled adjudication of facility claims
- Application of Coordination of Benefit, Drafted appeal letter
- Read DOFR’s to determine financial responsibility for payment
- Forwarded claims to Health Plan for responsibility
- Applied timely filing for other reductions that applied
- Read and interpreted provider contracts
- Checked website portals for authorizations
Medical Claims Examiner III
Care1st Health Plan
03.2011 - 08.2012
- Handled adjudication of facility claims for all POS / Bill Type
- Worked with 175 – 200 claims/day (High Volume)
- Stop-Loss, Outpatient/Inpatient Stay, and processed appeals/drafted letters
- Coordinated Benefits, Authorizations, DME and interpreted provider contracts
- Able to take on new projects, adjust claims, and request recoupment
Medical Claims Examiner II
United Healthcare
08.2007 - 06.2010
- Assisted and reviewed paper/electronic claims covered by PPO/HMO
- Worked on high dollar claims up to $1,000,000
- Worked with contracted (PAR) and non-contracted claims utilizing fee for service
- Met production of adjudicating 70 claims daily plus more
- Processed claims for SIU, and determined if further investigation was needed
- Used my knowledge of CPT/HCPC and ICD-9 coding, procedures and guidelines
- Stop-Loss, DRG, Outpatient/Inpatient Stay, Professional Claims
- Coordinated benefits authorizations, eligibility, DME and interpreted provider contracts
- Excellent research, analysis and accounting abilities with 100 % accuracy
- Maintained compliance with industry regulations and company policies while evaluating medical claims for accuracy and legitimacy.
- Collaborated with healthcare providers to obtain necessary medical records, ensuring timely and accurate claim adjudication.
Education
Diploma - Business Administration
Maric College
Anaheim, CA01.2004
Skills
- Stop-Loss Claims Coordination
- Reimbursement
- Claims Adjudication
- Denials Management
- Aggregate Reporting
- Advance Funding
- RFPs
- Policy Interpretation
- Coding
- ICD-10
- CPT
- DRG
- COB
- EOB Review
- CMS-1500 Processing
- UB-04 Processing
- Insurance Lines
- Medicare
- Medicaid
- Medi-Cal
- HMO
- PPO
- Managed Care
- HealthAxis
- GBAS
- OnBase
- MITZ
- EHealth
- TP Advantage
- MS Office Suite
- Multi-tasking
- Prioritization
- Customer Relations
- Customer service
- Critical thinking
Timeline
Customer Service Representative
TRC/ Job and Family Services
12.2024 - Current
Front Office Assistant
First Step Recovery
10.2024 - 12.2024
Stop-loss Coordinator
Consociate Health - NTT Data(Contracted)
01.2024 - 05.2024
Stop-loss Coordinator
Healthscope Benefits - UMR/United Healthcare
08.2018 - 04.2023
Claims Examiner III
Accountable Health Care - ATI
11.2012 - 12.2017
Medical Claims Examiner III
Care1st Health Plan
03.2011 - 08.2012
Medical Claims Examiner II
United Healthcare
08.2007 - 06.2010
Diploma - Business Administration
Maric College
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