L. Marie Ransleben
Healthcare Medical Claims Examiner/Analyst
Fredericksburg,TX
Summary
Opportunity to contribute my acquired skills within a growing Healthcare environment. Claims Examiner with deep knowledge of medical, personal injury and workers compensation claims industry. Solid abilities in developing objectives and strategies to settle all claims. Excellent skills compiling, coding, categorizing and auditing information to process claims.
Overview
25
25
years of professional experience
Work History
Claims Examiner
Guidewell Florida Blue dba Webtpa
04.2023 - Current
- Currently working as Claims Examiner on company’s largest plan administered by company is Prudential
- The system used to pay these claims is iiput system
- Claims are divided up by alpha split to examiner to work and type of claim when paying
- The claims are unscrubbed and examiner is responsible for confirming all information on claims such as paid to member or subscriber, provider information (TIN, NPI), amounts, POS, REV code and if the correct benefit feeds through the system and whether it requires a pre authentication; which may be in system referrals or we have to lookup in Jiva system to see if it is on file
- Company requires 100% accuracy.
Realtor
Fathom Realty
01.2006 - Current
- Credentials include Texas Affordable Housing Specialist, Short Sales/Foreclosure Sales, Seller Representative, Residential Construction Consultant, Graduate Realtor Institute
- Specializing in Residential, Land/Ranch, and Leases
- Includes all phases of sales – marketing, accounting, socializing/networking, compliance of regulations and laws regarding Texas real estate law.
Collections Specialist
Transworld dba Convergent USA
11.2022 - 03.2023
- Third Party Administrator for individual companies administering collection practices for the hiring company
- Ability to view available notes and dates of service seen in hospital, as well as insurance information, who is responsible party, current contact information
- All information has to be contacted and confirmed
- Sometimes we would have to contact individual for information or City, State or highway department that issued ticket for additional information to file outstanding charges
- Hospital system available for collection of data as well.
Independent Contractor for Complaint Appeals Board
Blue Cross/Blue Shield
01.2018 - 01.2023
- Escalated complaint review by all appropriate parties to arbitrate and review file documentation to process and make recommendations based on Plan provisions or have been paid according to plan or consider if this is out of plan mileage range or if an exception should be made and consideration be given as transitional care
- Attend CQIC monthly meeting to process meeting reports on monthly, quarterly reports by departments reporting to Clinical Director
- Reports include systems, trends, and turnaround times, new plan products, services, etc
- Listen and suggest recommendations to develop and improve process, ask questions, and contribute opinions.
Remote-Claims Analyst
Boon-Chapman
11.2021 - 10.2022
- Third Party Administrator for Individual companies administering plans (self-funded, PPO, HMO, etc) with specific benefits
- Ability to read plans and apply benefits accordingly
- Coordinate Benefits either on a carve out basis or coordination basis according to the birthday rule and whether a policy is active or retired employee, if spouse is working, disabled or on ESRD, or cobra
- Trained on Adjustment’s for underpayments, overpayments, appeals, on all types of claims
- Plan benefits that require pre auth and which one’s don’t are very specific on plans
- Knowledge of NSA guidelines, plan benefits that wrap benefits.
Pathology Lab Assistant
Pathology Reference Lab
01.2005 - 01.2006
- Prep and collections of surgical specimens from hospitals departments/individual physicians; for slide review by pathologist analysis
- Knowledge of Hospital Billing system for documentation and billing purposes.
Claims Manager/Collections
Self Employed
01.2005 - 01.2003
- Knowledge of HIPAA regulations, ICD-9, CPT and HCPCS coding to bill and rebill corrected healthcare claims including Physician healthcare, Personal Injury Protection, Workers Comp and Healthcare claims for HCFA and UB billing, electronically and paper claims.
Sr. Claims Analyst
Fiserv (Benefit Planners)
01.1999 - 01.2003
- Third Party Administrator for Individual companies administering claims processing adjudication, analyzing appeals, pre-authorized services, and adjustments on individual accounts
- Broad knowledge of documentation, communication logs, project management using FACTS database software and attention to individual plan details for accurate payment of claims
- Training for new plans and auto adjudication improvement of workflow
- Also training in setting up systems/database software to pay according to individual plan specifications
- General knowledge of company software for all phases of the claims processing
- Work closely with all interrelated departments on assigned projects.
Education
Skills
PIP Claims Processing
Workers Compensation Claims Processing
CPT,HCPCS,ICD9 and 10, modifers
HCFA and UB Billing and Collections
Relevant Work History
- 10/1998, 02/1999, Customer Service Rep., Texas Municipal League
- 07/1996, 10/1997, Team Lead/Claims Analyst, USA Health Network dba Fountainhead
- 05/1992, 07/1996, Medical Director Administrator, Kerrville State Hospital
- 08/1991, 05/1992, Clinical Director Secretary, Hill Country Memorial Hospital
- 07/1982, 08/1991, Support Staff Supervisor, TXDOT – Lemon Law Division
Qualifications Summary
- 6 Years – Acknowledge and listen to escalated Appeals for decision to agree or overturn based on information presented.
- 6 Years – Attending and analyzing data provided at Clinical Quality Assurance Meetings for possible improvements.
- 6 Years – Knowledge of CPT, ICD9 and HCPCS coding and their usage for appropriate billing.
- 6 Years – Claims and Collections: All types Medical, Hospital, Workers Comp., PIP, subrogation, Appeals and adjustments etc. Processing claims, customer service, documentation requirements. Understanding of Claims Software (FACTS) systems with ease
- 15+years – Administrative experience for and with professionals at all levels.
- 4 Years – Supervisory and Management of support staff.
- 15+Years – Understanding of HIPAA, Birthday Rule, NSA and COB guidelines regulations and requirements. Customer Service, expertise in listening, problem solving and referring to appropriate resource.
References
- Kathy Galloway, 210-656-6763
- Michael New, 210-843-2174
- Lee DeLuna, 210-748-7329 or 972-268-4372
- Russell Harding, 512-474-1801
- Carl Evans, 830-997-0856 or 830-990-3027
- Danielle Peters, 972-766-2554
- Tanna Rose, 405-640-2737
- Erin Bryne, 540-690-5389
Timeline
Claims Examiner
Guidewell Florida Blue dba Webtpa
04.2023 - Current
Collections Specialist
Transworld dba Convergent USA
11.2022 - 03.2023
Remote-Claims Analyst
Boon-Chapman
11.2021 - 10.2022
Independent Contractor for Complaint Appeals Board
Blue Cross/Blue Shield
01.2018 - 01.2023
Realtor
Fathom Realty
01.2006 - Current
Pathology Lab Assistant
Pathology Reference Lab
01.2005 - 01.2006
Claims Manager/Collections
Self Employed
01.2005 - 01.2003
Sr. Claims Analyst
Fiserv (Benefit Planners)
01.1999 - 01.2003