Patricia DuBois
Atlanta,USA
Summary
Experienced Insurance professional with over 30 years of experience in Medical Insurance Claims Investigation, Processing Services. Dedicated to Health Care Fraud, Financial Accuracy, Waste and Abuse within the Healthcare System.
Overview
32
32
years of professional experience
Work History
Healthcare Claims Analyst
Sun Technologies, Inc
09.2024 - 11.2024
- Responsibilities were the following- to manage the end-to-end claims process, from submission to resolution, identified and addressed any discrepancies or issues.
- Utilise automated claims administration systems to manage and process claims efficiently.
- Collaborate with healthcare providers, insurers, and other stakeholders to resolve claim disputes and ensure timely payment.
- Conduct regular audits and review of claims to ensure compliance with regulatory requirements and internal policies.
- Generate and analyse reports on claims activity, identifying trends and areas for improvement.
- Provide technical support and training to team members on the use of claims administration systems.
- Stay updated with changes in healthcare regulations and claims processing guidelines.
- Assist in the development and implementation of policies and procedures to enhance claims processing efficiency and accuracy.
Claims Consultant
PBD Healthcare Advocates
12.2019 - 09.2024
- Assist Health Insurance companies with benefit implementation, create business processes, define strategies with HealthCare Domains.
- Consult with individuals as needed.
- Advocate for individuals with claims and benefit issues.
- Contact insurance companies to follow-up on claims which were denied or are pended. Assist members in resolving claims payment issues and advise.
Senior Claims and Business Analyst
The World Trade Center Health Program (WTCHP/NIOSH)
01.2017 - 09.2019
- Serving as the primary point of contact with WTC Health Program Support on claims issues.
- Reviewed medical records, conducted research, and provided expert guidance on complicated and/or high-cost claims, denials, refunds, appeals and recoupments.
- Adhered to WTCH Program Fraud Waste and Abuse policy. Took measures to prevent, detect and deter the FWA of public funds.
- Investigated medical insurance claims submitted to the WTC Health Program for payment and ensured the conditions were WTC connected and payable by the Program.
- Determined if the diagnosis codes, procedure codes, provider specialty, and financial information were related to the services provided.
- Implement claims operations solutions with the Health Program Support (HSP) contractor to meet WTC Health Program requirements and to ensure process optimization.
- Applied medical coding knowledge and communicated claim issues with WTC Health Program Team Leads and other Subject Matter Experts (SME) to assess the impact and determine the appropriate solutions.
- Document and implement claim payment process recommendations that meet regulatory requirements and claim business rules before providing guidance to the HPS contractor.
- Create effective written and oral communication materials that summarize findings and support fact-based recommendations to the WTC Health Program Medical Operations Group, Core Management Team, and Quality Assurance Group as required.
- Reviewed claim systems utilization, capacity analysis/planning, report claims-related business and systems analysis from the HPS contractor.
- Analyzed claims database and reporting on status, researched claims.
- Provide advice on claims system and/or configuration design as well as participate in design planning such as test development and implementation.
- Prepared monthly summary of actions report and provided to the WTC Health Program Quality Assurance Officer.
Claims Operations Manager
Kaiser Permanente
03.2015 - 10.2015
- Executed the daily operations of the Third-Party Administration consulted with the TPA leadership to defined processes, approach requirements and strategy.
- Planned, Facilitated, Coordinate, Project Managed, scheduled meetings, documented, performed analysts.
- Served as the Subject Matter Expert (SME) between Kaiser Permanente Insurance Company and the Self-Funded Plan Sponsors/TPAs, along with the Audit vendors to ensure successful audits.
- Performed Quality Audits of the Denial Management Files.
- Met with all the Regions to go over the monthly claims’ denial management process.
- Managed any issues resolution with the regions and TPA.
- Provided team support on issues requiring specific SME skills.
- Facilitated production issues resolution with multiple regional teams including teams such as Member Escalation, KPIC IT, Regulatory
- Coordinate the daily, weekly, and monthly meetings to address and resolve escalated issues.
- Traveled to the Third-Party Administration office monthly and managed the Auditing Process.
- Managed the Third-Party Administration Team which consisted of over 100 employees as well as the Client Auditing Team.
Lead Quality Assurance Auditor
Kaiser Permanente
08.2008 - 03.2015
- Developed and conducted end-to-end audits to monitor and determine financial accuracy, consistency, timeliness, health care fraud and integrity of the coded benefit data such as benefits, plans, essential contract, benefit data and output files in a variety of benefit systems.
- Analyzed data and provided clear, concise audit reports to Analysts and Case Management Team.
- Provided training as assigned to new employees as well as cross trained in all phases of claims and referral department process.
- Provided ongoing feedback to improve quality results.
- Developed recommendations based on audit findings to resolve problems impacting the accuracy and consistency of data and benefit entry within the contract and benefit systems.
- Work closely with the Claims Audit team and the Appeals units to identify, trend analysis and find root causes for errors which impacted the members and employer rates, claims payments and benefits.
- Implemented cross-functional business process improvement plans to increase quality and decrease errors on the end-to-end member experience with HPSA departments (call center, claims, etc.). Worked closely with the Integration Analyst to develop standards for benefit naming and documentation conventions.
- Identified opportunities for improving system formats and functionality to increase efficiencies and user acceptance.
- Analyzed and Interpreted data for Epic application for configuration prior going live and provided feedback based on performance monitoring results.
Lead Medical Claims Processor
Blue Cross And Blue Shield Of Georgia
03.2003 - 08.2006
- Respond to correspondence from members and providers, adjudicated medical, COB, anesthesia, and Medicare claims.
- Managed large volume of medical claims on daily basis.
- Maintained knowledge of benefits claim processing, claims principles, medical terminology, and procedures and HIPAA regulations.
- Used administrative guidelines as resource or to answer questions when processing medical claims.
Medical Claims Analyst
Administrative Services Inc, TPA
02.1997 - 01.2003
- Third Party Administrator for over fifty local unions, Using CPT and ICD-9 Codes along with Medical Terminology, calculated and adjusted medical and surgical claims.
- Accountable for the accurate review, adjudication and resolution of health insurance claims based on each specific plan benefit guidelines.
- Updated member eligibility files which facilitates the coordination of benefits (COB) for the insured members.
Education
Liberal Arts and General Studies
Johnson & Wales University
Providence, RI03.1983
Skills
- Claims and Benefits Auditing
- Benefit Configuration for Epic/Tapestry Systems
- Medical Terminology CPT, ICD-10 Coding
- Microsoft Office
- Access & Excel
- 10 Years Medical Claims Processing
- 10Years Customer Service Experience
- Benefits Administration and Implementation
Timeline
Healthcare Claims Analyst
Sun Technologies, Inc
09.2024 - 11.2024
Claims Consultant
PBD Healthcare Advocates
12.2019 - 09.2024
Senior Claims and Business Analyst
The World Trade Center Health Program (WTCHP/NIOSH)
01.2017 - 09.2019
Claims Operations Manager
Kaiser Permanente
03.2015 - 10.2015
Lead Quality Assurance Auditor
Kaiser Permanente
08.2008 - 03.2015
Lead Medical Claims Processor
Blue Cross And Blue Shield Of Georgia
03.2003 - 08.2006
Medical Claims Analyst
Administrative Services Inc, TPA
02.1997 - 01.2003
Liberal Arts and General Studies
Johnson & Wales University