Microsoft Office
Loresa McCullough
Weatherford,TX
Summary
Adept Medical Claims Analyst with a proven track record at Centene, enhancing fraud detection and boosting customer satisfaction through meticulous claim analysis and process improvements. Skilled in HIPAA compliance and claims processing, coupled with exceptional problem-solving and communication abilities, excel in high-pressure environments, ensuring accuracy and efficiency in handling insurance claims. Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals.
Overview
12
12
years of professional experience
1
1
Certification
Work History
Medical Claims Analyst
Centene
03.2015 - Current
- Reduced fraudulent claims by conducting thorough investigations and collaborating with the fraud detection.
- Improved customer satisfaction by resolving complex medical claims in a timely and professional manner.
- Assisted in the development of standardized processes for claim adjudication across multiple insurance products.
- Ensured accurate payments by meticulously reviewing medical records, invoices, and supporting documentation.
- Maintained knowledge of benefits claim processing, claims principles, medical terminology, and procedures and HIPAA regulations.
- Monitored and updated claims status in claims processing system.
- Paid or denied medical claims based upon established claims processing criteria.
- Managed large volume of medical claims 50-60 on daily basis.
- Evaluated medical claims for accuracy and completeness and researched missing data.
Customer Service Representative
Convergys
06.2012 - 03.2015
- Answered customer telephone calls promptly to avoid on-hold wait times.
- Managed high call volume, consistently maintaining professional demeanor and prioritizing customers'' needs.
- Built rapport with clients through active listening, empathy, and understanding of their individual needs.
- Maintained high level of integrity and confidentiality when handling sensitive customer information, ensuring data privacy compliance.
- Navigated multiple systems simultaneously for efficient information retrieval during live calls with customers.
- Adhered to company guidelines and protocols while representing brand professionally during all interactions with customers.
- Managed high-stress situations effectively, maintaining professionalism under pressure while resolving disputes or conflicts.
Education
High School Diploma -
05.2012
- 3.5 GPA
- Honoree of Texas Scholar
Some College (No Degree) - CCMA
Skills
- Claims Processing Proficiency
- HIPAA Compliance Understanding
- Medical Terminology Familiarity
- Training and mentoring
- Insurance Policies Knowledge
- Customer Service
Certification
Certified Clinical Medical Assistant
Work Availability
monday
tuesday
wednesday
thursday
friday
saturday
sunday
morning
afternoon
evening
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Work Preference
Work Type
Full TimeLocation Preference
On-SiteImportant To Me
Work-life balanceCareer advancementPersonal development programsPaid time off401k matchCompany CulturePaid sick leaveSoftware
Microsoft Teams
Citirix
Languages
English
Interests
Improving knowledge/experience
Timeline
Medical Claims Analyst - Centene
03.2015 - Current
Customer Service Representative - Convergys
06.2012 - 03.2015
Jacksonville High School - High School Diploma,
Necole's Learning Academy - Some College (No Degree), CCMA