Lindsay Ramirez
Becker,MN
Summary
Highly analytical and service-oriented professional with extensive experience in claim recovery, medical necessity guideline implementation, compliance management, and legal administration within the health insurance industry. Proven track record of reviewing claim adjustments, training employees, maintaining procedures, and promoting new products. Instrumental in delivering top-notch customer service by recognizing and reporting claim underpayments, implementing cost containment measures, conducting audits, and identifying potential issues. Strong communication, multitasking, time management, computer, and teamwork skills. Technically proficient in ICD-10-CM, HCPCS, CPT coding, audit, Salesforce, DG software, Microsoft Office Suite, inventory management, and cash handling.
Overview
15
15
years of professional experience
Work History
Analyst-Client Services, MHI Implement and Plan Build Department
Meritain Health, Aetna
08.2022 - Current
- Build and audit medical and dental plans as a second form of audit
- Work with the plan build department to development consistent processes, policies, and procedures
- Review benefit builds in database against new plan documents to identify potential discrepancies
- Facilitate meetings to discuss the known discrepancies and collaborate with all parties involved to find a consistent solution to prevent negative impact to the client
- Collaborated with cross-functional teams to identify opportunities for process improvement and increased efficiency.
- Enhanced team collaboration by providing clear communication of complex findings through visualizations and reports.
Sr. Claims Benefit Specialist, Adjustments and Recovery - Claims Department
Meritain Health, Aetna
01.2016 - 08.2022
- Manage claim eligibility determinations while researching contracts and other documentations
- Play an instrumental role in claim adjudication process by applying medical necessity guidelines, determining coverage, completing eligibility verification, identifying discrepancies, and implementing cost containment measures
- Upgrade first-claim/re-consideration database through efficient telecommunication
- Ensure compliance with HIPAA, state and federal government regulations and company specific payment procedures by implementing medical necessity guidelines
- Determined liability and minimized reflags while reviewing/adjusting complex, sensitive, specialized, Medicaid and Medicare claims
- Ensured zero disappearances while recognizing and reporting claim underpayments, overpayments, and other irregularities to senior management
- Enhanced claim processing efficiency by streamlining workflows and implementing best practices.
- Resolved complex claims issues for improved customer satisfaction and reduced claim backlog.
- Facilitated communication between departments, ensuring timely resolution of outstanding claims.
- Contributed to team success by sharing expertise on complex cases and collaborating on strategies to increase efficiency in case management tasks.
- Assisted in the development of department goals and objectives, actively working towards achieving them through individual performance metrics tracking efforts.
- Managed high-volume caseloads, consistently meeting deadlines and maintaining accuracy in claim review.
Claims Analyst
Assurant Health
03.2015 - 04.2016
- Streamlined claim operations by demonstrating clear understanding of procedures, including claim systems, claim reviews, adjudication processes, and multiple policy types
- Delivered quality service through accurate processing of dental, medical and specialty claims
- Ensured proper consideration of benefits while reviewing and researching necessary information of claims
- Boosted work efficiency while assisting in establishment and creation of new processes
- Addressed process related queries/referrals to ensured seamless workflow while acting as team mentor
- Utilized multiple source references to create claim determinations
- Raised productivity, eliminated redundancies, and improved customer experience by recognizing/supporting process improvement strategies
- Enhanced professional skills through active participation in claim projects and user testing process
- Exceeded productivity expectations while serving in remote working environment
- Maintained strict confidentiality with all personal data as per company guidelines.
- Managed high-volume caseloads, prioritizing tasks to ensure timely completion of all claims.
Health Plan Representative
Kaiser Permanente
01.2014 - 04.2014
- Enhanced company reputation by providing exceptional customer service and support.
- Greeted customers warmly to set tone of customer experience and provide welcoming and friendly atmosphere.
Sr. Teller
Chase Bank
06.2009 - 08.2013
- Resolved complex customer issues promptly and professionally, maintaining a focus on achieving positive outcomes for both the client and the bank.
- Delivered exceptional service while managing high-volume cash transactions during peak business hours without compromising accuracy or efficiency levels.
- Conducted thorough audits of teller cash drawers, vaults, and ATMs, contributing to branch compliance with internal controls and regulatory standards.
- Enhanced customer satisfaction by efficiently processing transactions, addressing inquiries, and providing tailored financial advice.
- Boosted branch sales performance with proactive cross-selling of bank products and services to meet individual customer needs.
- Meticulously monitored cash drawer activity, ensuring accuracy in transaction processing and adherence to strict security protocols.
- Coached and trained Number of new bank tellers.
- Handled foreign currency and performed currency transaction reports.
- Promoted positive customer interactions, consistently maintaining a professional demeanor during high-pressure situations.
Education
Bachelors of Business Administration - Emphasis in Finance
Brandman University
Fairfield, CASkills
- Claims Analysis
- Cooperate Relations
- Problem Resolution
- Audit Reporting & Documentation
- Redundancies Elimination
- Coverage Determination
- Leading calls
- Compliance Management
- Employee Empowerment
- Strategy Development
- Analytical Thinking
- MS Excel
- Team Collaboration and Leadership
- Documentation And Reporting
- Excel proficiency
- SQL and Databases
- Root Cause Analysis
- Report Preparation
- Compliance Analysis
- Audit Support
- Process enhancement
- Continuous Improvement
- Process Improvements
- Information Gathering
Timeline
Analyst-Client Services, MHI Implement and Plan Build Department
Meritain Health, Aetna
08.2022 - Current
Sr. Claims Benefit Specialist, Adjustments and Recovery - Claims Department
Meritain Health, Aetna
01.2016 - 08.2022
Claims Analyst
Assurant Health
03.2015 - 04.2016
Health Plan Representative
Kaiser Permanente
01.2014 - 04.2014
Sr. Teller
Chase Bank
06.2009 - 08.2013
Bachelors of Business Administration - Emphasis in Finance
Brandman University
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