LISA RIVERA-HENSLEY
Mountlake Terrace,WA
Summary
Claims Associate III with a strong focus on results and expertise in claims investigation and processing. Demonstrated success in improving team performance through targeted training and collaboration. Skilled in ICD-10 and adept at problem-solving, consistently maintaining high accuracy in claims processing and compliance. Committed to exceptional service and efficient resolution of complex issues.
Overview
11
11
years of professional experience
Work History
Claims Associate III
Premera Blue Cross
Mountlake Terrace, WA
01.2016 - 10.2024
- Analyzed and processed claims, ensuring accuracy and adherence to performance goals.
- Audited claims for accuracy, identifying discrepancies and rectifying errors.
- Trained Claims associates on processes and pending codes to enhance team competencies.
- Verified provider credentials and license status to maintain compliance standards.
- Requested medical records from provider offices to support claim evaluations.
- Monitored reports to identify claims issues, and worked with processors to resolve problems.
- Reviewed medical travel reimbursement requests, confirming receipt validity and eligibility.
- Created letters to members and providers for information gathering purposes.
- Managed DSHS reimbursements and Coordination of Benefits (COB) effectively.
- Retained strong medical terminology understanding in effort to better comprehend procedures.
- Monitored the expiration of licenses and certifications of providers when processing claims submitted directly from members.
Customer Service Representative
Premera Blue Cross
Mountlake Terrace, WA
01.2014 - 01.2016
- Achieved 'First Call Resolution' through effective handling of inbound and outbound calls.
- Quoted benefits and addressed inquiries for both members and providers.
- Ensured security protocols for sensitive member information were strictly followed.
- Updated members and providers promptly regarding claim statuses.
- Managed paperwork efficiently during downtime to maintain workflow continuity.
- Worked with cross-functional teams to achieve goals.
- Demonstrated strong problem-solving skills, resolving issues efficiently and effectively.
- Identified needs of customers promptly and efficiently.
Education
High School Diploma -
Cascade High School
Everett, WA06-1998
Skills
- Time management
- Claims investigation
- Teamwork and collaboration
- Organizational skills
- Critical thinking skills
- Knowledge of ICD-10
- Problem solving
- Medical terminology
- Claims processing and adjustments
- Auditing claims
- Coordination of benefits
- HIPAA compliance awareness
- Understanding of Medicare
Timeline
Claims Associate III
Premera Blue Cross
01.2016 - 10.2024
Customer Service Representative
Premera Blue Cross
01.2014 - 01.2016
High School Diploma -
Cascade High School
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