MARY MCCLAIN
Humana
Seaboard,NC
1
year of post-secondary education
9
years of professional experience
Methodical Medical Claims Analyst experienced in medical claims and case management. Delivered accurate claims processing and appeals coordination through strong investigative skills and attention to detail. Focused on maintaining compliance with HIPAA regulations while enhancing communication with healthcare providers and resolving discrepancies.
Work History
Enrollment Specialist
6 Months- Validated eligibility and benefit elections, ensuring accuracy of retroactive adjustments and reinstatements before final processing.
- Conducted back-end review of enrollment transactions using CAS Claims, MARx, MACEES, EMME, CRM, SPIDAR, and FASTAPP to ensure data integrity.
- Investigated discrepancies across multiple systems and collaborated with internal departments to resolve issues, enhancing overall enrollment accuracy.
- Maintained detailed documentation in CRM and OneNote while following established procedures and regulatory requirements.
- Handled sensitive member information while maintaining HIPAA and PHI confidentiality.
- Managed high-volume work independently while maintaining accuracy and meeting established processing requirements.
Medical Data Analyst
4 Years 11 Months- Evaluate Facts, Policy Coverage & Interpret Law Regulations
- Rendered compensability and medical determinations to ensure compliance with regulations
- Mitigated risks of inaccurate or incomplete patient records through rigorous quality control checks
- Manage high volume of incoming claims calls, consistently meeting deadlines without compromising accuracy or quality
- Resolved claim disputes by exercising active listening, conducting thorough investigations, and presenting findings clearly and concisely
- Maintain strong relationships with healthcare providers to facilitate efficient information exchange regarding patient eligibility and benefits coverage
- Worked remotely to manage tasks efficiently
Case Manager (Independent Contractor)
3 Years 11 Months- Provided Case Management exclusively for an adult male client diagnosed with major mental health issues
- Educated family on coping strategies and supportive techniques, enabling them to effectively manage challenging behaviors at home and in public
- Provided crisis intervention for a client during emergencies to de-escalate situations safely
- Educated family on coping strategies and supportive techniques to enhance their ability to manage challenging behaviors at home or in public effectively
- Documented and communicated patient progress and treatment recommendations to multiple medical providers, ensuring coordinated care and comprehensive treatment
- Conducted assessments to determine individual needs and developed personalized care plans to address stated objectives and monitored the client at his work site weekly
Education
- Computer And Information Sciences
Computer Technology Certificate - Computer Technology
Skills
Enrollment transactions
Eligibility verification
Claims Processing Accuracy
MARx processing
HIPAA Compliance
Medical Terminology
Insurance Policy Interpretation
Data management
Microsoft Office Suite
Case Management
Customer Service Excellence
Active Listening
Timeline
Enrollment Specialist
Humana
09.2025 - 03.2026Read More
Martinsburg College
from Computer And Information Sciences
04.2024 - 12.2024Read More
Medical Data Analyst
Sagility
01.2021 - 12.2025Read More
Case Manager (Independent Contractor)
Private Family
01.2017 - 12.2020Read More
Computer Technology Certificate from Computer Technology
Read More