Loretta Sanders
Phoenix,AZ
Summary
Looking for a permanent position as a Clinical Claims Analyst, Medical Assistant or Insurance/Referral specialist where my experience in patient processes will be utilized. In addition to assist Medical Facilities by providing quality care and team work and continue to assist patients in healthcare requirements.
Overview
11
11
years of professional experience
Work History
Clinical Claims Adjustment Associate
United Healthgroup
Phoenix, AZ
01.2018 - Current
- Reviews, investigates, and accurately processes medical claims, ensuring compliance with policy terms, coding standards (ICPD/CPT), and regulations. resolve discrepancies, manage COB (Coordination of Benefits), and determine reimbursement amounts.
- Claims Processing: Review and process medical claims (electronic or paper) for accuracy, completeness, and compliance with payer requirements.
- Investigation & Resolution: Investigate, negotiate, and resolve complex claim issues, including COB (Coordination of Benefits).
- Documentation & Accuracy: Verify patient eligibility, provider credentials, and medical documentation, flagging discrepancies and errors.
- Compliance: Adhere strictly to HIPAA regulations and internal company policies, ensuring high-quality standards in a fast-paced environment.
- Communication: Interface with providers, patients, and internal teams to resolve claim discrepancies and assist with appeals or resubmissions.
Clinical Referral Coordinator
United Healthgroup
Phoenix, AZ
01.2015 - 12.2017
- Referral coordinator, processing, data entry, respond to Incoming Provider and Enrollee calls.
- Resolve Customer Service inquiries; provides excellent Customer Service to both Providers and Enrollees.
- Constantly meet established productivity, schedule adherence, and quality standards while maintaining good attendance.
- Receives Care Coordination notification cases for non-clinical assessment/intervention and provides appropriate triage, processes out of network requests for consideration of in network level of benefits for physician specialty referrals for appropriate products.
- Processes notification requirements for outpatient procedures, home health, DME, transition of care, and network gap issues and determines benefit coverage issues based on employer group contracts.
- Sets up/documents/triages cases for (CCR) Clinical Coverage Review
- Ensures all potential member needs are identified and forwarded to the appropriate Care Coordinator for risk validation when applicable, processes letters within DOL time frames.
- Verifies appropriate ICD-10 and CPT coding usage, communicates to providers and members benefit determinations within DOL time frames and assists with faxes and emails.
- Moderate work experience within own function, some work is completed without established procedures and basic tasks are completed without review.
- Supervision/guidance is required for higher-level tasks.
- Other duties as assigned by manager and/or director.
Education
Diploma For Medical Assisting - Medical Assistant
Arizona Institute of Business And Technology
Phoenix, AZ12-1996
Skills
- Microsoft Powerpoint
- Organizational skills
- Microsoft Outlook
- Data entry
- Analysis skills
- Typing
- Microsoft Excel
- CPT coding
- Microsoft Word
- Medical Terminology
- Microsoft Office
- Health Insurance
- Customer Service
- Critical Thinking
Timeline
Clinical Claims Adjustment Associate
United Healthgroup
01.2018 - Current
Clinical Referral Coordinator
United Healthgroup
01.2015 - 12.2017
Diploma For Medical Assisting - Medical Assistant
Arizona Institute of Business And Technology