Summary
Overview
Work History
Skills
Affiliations
Timeline
Generic

Margaret Terry

International Falls,MN

Summary

I am seeking a new career position as a Sr. Recovery / Resolutions Analyst - National Remote.

Utilizing my 35 years of claims experience.

Overview

35
35
years of professional experience

Work History

Reconciliation Manager

Optum
01.2020 - Current
  • Develop training program and successfully train 10+ individuals on the process for reconciliation of estimated payments and negative balance
  • Provide coaching to continue increasing team performance
  • Collaborate with internal departments to correct discrepancies with finance, claims, eligibility, authorizations, and provider setup
  • Assist external providers in using Excel documents alongside provider accounts receivable to reconcile estimated payments with claims submitted prior to recoupment of overpayments
  • Collaborate with internal departments to correct discrepancies with claims, eligibility, authorizations, and provider setup
  • Partner across the company to build strong networks to drive change and improvement while anticipating potential problems and solving problems
  • Nominated internally for many awards from colleagues and other internal departments (Ex: Bravo for performance, relationships, and leadership; Superhero nomination)

Sr. Quality Analyst Benefit Configuration

Optum
10.2015 - 01.2020
  • Audit new Benefit Configuration
  • Provide expertise in all areas of the claims configuration process by reviewing and auditing claims and configuration to ensure that all internal processes have been followed and that we are compliant with contractual and regulatory requirements
  • Assess Defects
  • Serve as a Subject Matter resource
  • Works as key member of a team to analyze and identify error trends and provide recommendations and feedback to reduce errors and improve claims processes and performance
  • Test claims to ensure system is processing claims correctly
  • Processed test claim on the BIC platform (Benefit Intent Certification)
  • Worked with Project Teams with BIC upgrades (UAT Testing)
  • Track Audits in Quality Insight
  • Created ways for process improvements
  • Trained and mentored other employees
  • Maintained Quality Insight program for the team
  • Worked with Project Teams to Upgrade Quality Insight (UAT Testing)
  • Communicate with the Health Plan
  • Create New Policy and Procedures
  • Maintain the Corporate SharePoint
  • Attend Daily Meetings
  • Worked with Sarbanes External Audit
  • User Acceptance testing for Quality Insight Platform
  • Work with the Health Plan to resolve defects
  • Plan View – Allocate time

Sr. Configuration Analyst OHBS

Optum
09.2010 - 10.2015
  • Manage HealthPlan service desk tickets for users who have issues on the Facets claims system
  • System functionality
  • Claims payments issues
  • Triaged claims that were not falling into the correct queues and roles and resolved any issues
  • Built new Workflow Configuration for Behavioral claims, this includes building new: Qualifier Groups, Routing Rules, Queue Configurator, Role Definitions, Routing Reasons
  • Communicate directly with the HealthPlan on service desk tickets
  • Business Analyst in project capacities directly related to Facets
  • Work directly with business users
  • Work with business requirements and technical specifications
  • Communicating directly with development teams
  • Participate in user acceptance testing
  • Plan-view – Allocating time
  • Weekly status reports to Manager
  • Attend weekly Meetings
  • Work closely with team members daily
  • Added Configuration for the following Tables: Procedure Codes, Diagnosis Codes, Service Definitions, Service Procedure Conversion, Supplemental Procedure Conversion
  • FACETS 5.1 Upgrade Project
  • Created test claims
  • Validation of the FACETS to Current Production System

Subject Matter Expert (Dental)

Optum
04.2001 - 09.2010
  • Serve as a resource to the dental Team(s) in an efficient and effective manner to ensure accurate and consistent claim processing/adjudication
  • Maintain all Dental Practitioner issues
  • HOVServices – Non-Keyable Document Management System
  • OptumHealth Service Requests; Claim set up issues
  • Maintain all Pending issues
  • Field Questions and serve as a secondary resource
  • Responsible for complex claim issues
  • Work independently and make decisions
  • Write and implement Policy and Procedures
  • Have effective communication skills both written and verbal
  • Keep accurate and timely records
  • Facilitate meetings with specific teams
  • Provide feedback for any trending issues
  • Maintain positive customer relations with internal and external customers
  • Serve as a resource for the San Antonio Texas call center, Nevada Claims, Gurgaon India & both claims processing Vendors
  • Work with Trizetto and the IT teams for any FACET or Siebel system issues
  • Customer Service calls to provider for missing information

Field Service Representative

Optum
07.1995 - 04.2001
  • Kept accurate and timely review, research and resolution of Physician and Hospital Adjustments
  • Communicated with the provider and member service through each Specific Health Plan
  • Kept accurate, daily, weekly and monthly reports
  • Maintained a 3-4 day turn around time on adjustments
  • Voided check process
  • Refund checks
  • Tracked system problems or claims submission trends
  • Assisted in cost effective ways to reduce adjustments

Medical Claim Reviewer

Optum
01.1992 - 07.1995
  • Kept accurate and timely review, research and resolution of Physician and Hospital claims that edited for review
  • Communicated with both provider’s and members to obtain more information and suggested resolutions so appropriate reimbursement could be made
  • Kept accurate daily, weekly, and monthly reports
  • Identified and tracked any system problems or claims submission trends
  • Assisted in maintaining current and accurate Policy and Procedures
  • Assisted in cost effective ways for processing Medical Insurance claims

Data Entry Processor

Optum
03.1991 - 01.1995
  • Accurately processed Physician claims in a timely manner
  • Kept an accurate logging system for all Health Plan cold storage
  • Kept accurate daily, weekly, and monthly reports

Pharmacy Claims Processor

Optum
06.1989 - 03.1991
  • Responsible for accurately processing Pharmacy claims in a timely manner
  • Track Daily production and submit a weekly report
  • Boxed, shipped, and tracked all processed claims sent to cold storage

Skills

  • Process improvement strategies
  • Conflict resolution techniques
  • Quality Assurance
  • Adaptable to market fluctuations
  • Data Analysis
  • Prioritizing and Planning
  • Strategy Development
  • Decision-Making
  • Business Relationship Management
  • Relationship Building
  • Financial Resource Management
  • Risk Assessment
  • Operational Reporting
  • Critical Thinking
  • Work Planning
  • Willing to Learn
  • Goal Setting
  • Customer Service
  • Proactive and Focused
  • Effective Communication
  • Team Building Leadership
  • Community Networking
  • In-Depth Research
  • Problem-solving aptitude
  • Problem-Solving
  • Capital Raising
  • Risk Analysis
  • Adaptability
  • Excellent Communication

Affiliations

  • Borderland Humane Society Holding Facility Manager

Timeline

Reconciliation Manager

Optum
01.2020 - Current

Sr. Quality Analyst Benefit Configuration

Optum
10.2015 - 01.2020

Sr. Configuration Analyst OHBS

Optum
09.2010 - 10.2015

Subject Matter Expert (Dental)

Optum
04.2001 - 09.2010

Field Service Representative

Optum
07.1995 - 04.2001

Medical Claim Reviewer

Optum
01.1992 - 07.1995

Data Entry Processor

Optum
03.1991 - 01.1995

Pharmacy Claims Processor

Optum
06.1989 - 03.1991

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Margaret Terry