Meelin Duran
Algodones,NM
Summary
I'm a skilled professional with strong written, verbal, analytical, financial and problem solving abilities. Worked specifically over the last several years to hone my skills as a strategic and financial thinker, a consensus builder, and more importantly, share my knowledge to help shape the healthcare industry. As such, my work ethic and level of integrity in the job are of the highest caliber; trust, transparency, and accountability drive my workplace value system. As a healthcare professional, it has been a opportunity to experience the many facets of the health care industry which allowed myself to work with providers, medical specialists, vendors, business stakeholders, and members to listen to their concerns and improve processes in a constant changing healthcare environment. Among my key accountabilities include; educating providers, monitoring large payments, identifying trending issues, implementing workflows to build and deploy effective payment strategies. The key principle of maintaining trusted relationships is intently listening, respecting ideas, collaborating, and implementing improved processes.
Overview
23
23
years of professional experience
Work History
Provider Relations Representative II
Western Sky Community Care
05.2023 - Current
- Enhanced provider satisfaction by addressing and resolving inquiries in timely manner.
- Reduced claim disputes by effectively communicating policy changes and updates to providers.
- Streamlined processes for provider credentialing, ensuring accurate documentation through Cenprov and Iscertis.
- Increased efficiency of provider relations team with implementation of tracking systems through JIRA, OMNI, CenPas, and Provider360.
- Collaborated with internal departments to resolve complex provider issues, maintaining positive relationships and open communication channels.
- Conducted regular audits of provider records, identifying discrepancies and ensuring accuracy in information.
- Analyzed data trends to identify opportunities for improvements within provider network and implement targeted strategies accordingly.
- Optimized operational workflows by identifying inefficiencies in current procedures and implementing necessary adjustments for increased productivity.
- Served as liaison between health plan, providers, and vendors to ensure seamless communication regarding claims processing and payment matters.
- Managed provider relations mailbox by triaging inquiries, facilitating resolution of incoming requests and forwarding requests to appropriate parties.
- Managed high-volume caseloads of claim dispute resolution cases, providing swift resolutions that maintained positive relationships with providers.
- Built simple queries to perform data analysis for payments, trending issues, and identify root cause through Golden.
- Utilize MicroStrategy daily to view reports for providers associated to claims, finance, provider records.
Claims Liaison
Western Sky Community Care
07.2018 - 05.2023
- Serve as liaison between health plan and providers to mitigate claims issues and payment.
- Collaborate with internal organizations to resolve claim issues; claims shop, provider relations, configuration, contracting, tribal relations, provider data management, coding and analytics team.
- Subject matter expert for Indian Health Providers, answering internal and external questions and inquiries.
- Review and submit provider rosters and W9 forms to credentialing team.
- Review pre-pay and post payment for providers to identify trending issues and provide global solutions for providers.
- Document work flows, job aids, and provide supporting documentation internally to solidify guidelines when addressing issues for Indian Health Providers.
- Conduct monthly meetings with providers to discuss outstanding payment, provide updates from health plan and address any issues presented by provider.
- Integrate efforts to reduce cost containment by ensuring configuration, provider records and workflows are maintained and streamlined to execute payment efficiently and timely.
- Urgently respond to state deliverables for Indian Health Providers
- Maintain yearly updated rates for providers and adjust claims in timely manner.
- Answer daily inbound calls from providers to provide support.
- Conduct on-site training as needed
Claims Auditor/Provider Network Administration Analyst
Molina Health Plan
01.2015 - 07.2018
- Demonstrated analytical and problem-solving ability by addressing detail research for provider service representatives and claims processors.
- Researched issues related to claims processing to identify origins and implement corrective solutions.
- Performed pre-pay and post-pay on claims to validate accurate payment.
- Maintain rate sheet for inpatient hospitals across New Mexico
- Examined high dollar claims and verified payment processing for level of care.
- Request adjustment and recoupment projects for Medicare, Centennial and Marketplace claims.
- Prescreen appeals for provider reconsideration request by reviewing attached documentation and routing to clinical staff for review.
- Developed job aids and standard operating procedures for Indian Health Providers.
- Tested claims for proposed rates and payment guidelines for provider's contract and ensured systems were configured accurately.
- Initiated cost containment by conducting thorough audits and data mining.
Claims Examiner
Blue Cross Blue Shield
11.2014 - 01.2015
- Processed payment and claim denials for Medicaid medical and dental claims.
- Verified member eligibility and provider record to ensure payment process was executed accordingly.
- Processed claims for multiple plans and states effectively and perform agility as with automated and manual differences in benefits
- Approving, pending, or denying payment according to accepted coverage guidelines.
- Communicated with internal customer relations for claims issues and ensuring accurate and complete claim information was collected and verified to process claim.
Claims Processor - Contractor for Alaska Medicaid
Xerox
05.2014 - 11.2014
- Processed Medicaid medical claims for state of Alaska.
- Examined and analyzed claims for accurate coding and validated member demographics.
- Reviewed explanation of benefits and coordinated benefits for proper coordination of payment.
- Ensured all guidelines were met according to state and government contracts for state of Alaska.
- Reviewed pended claims for claims issue.
Cytoprep Technician II
Quest Diagnostic Medical Laboratories
09.2001 - 05.2013
- Technical processing of bodily fluid/collecting cells and transferring onto slides.
- Executed diagnostics, troubleshooting and evaluations on bodily fluid for cytotechnologist and pathologist.
- Prepared various chemical reagents for slide stains and processing
- Data entry of requisitions including patient demographics, billing test codes, clinical information on patient and provider information.
- Out bound calls for problem resolution to clients and providers on laboratory testing, insurance eligibility.
- Trained new hire with technical processing and data entry for gynecological and non-gynecological specimens.
- Maintained inventory for laboratory supplies.
- Assisted Pathologist in preparing slides for medical evaluation on autopsy.
- Maintained all laboratory machine and equipment for daily and monthly maintenance.
- Assisted in preparation for audit and review by updating documentations and executing guidelines.
Education
Associate of Arts - Liberal Arts
Central New Mexico Community College
Albuquerque, NM04.2019
Certificate - Health Wellness And Public Safety
Central New Mexico Community College
Albuquerque, NM12.2018
Associate of Science - Applied Science
Central New Mexico Community College
Albuquerque, NM12.2018
Skills
- Complex problem resolution
- Extensive knowledge of medical terminology
- Experience with HMO, Medicaid, and Medicare contracts
- Excellent written and verbal communication
- Data collection and analysis
- Internal auditing
- HIPAA compliance
- Knowledge of Managed Care Organization contract
- Create job aids
- Claims Knowledge
- Provider relations skills
Timeline
Provider Relations Representative II
Western Sky Community Care
05.2023 - Current
Claims Liaison
Western Sky Community Care
07.2018 - 05.2023
Claims Auditor/Provider Network Administration Analyst
Molina Health Plan
01.2015 - 07.2018
Claims Examiner
Blue Cross Blue Shield
11.2014 - 01.2015
Claims Processor - Contractor for Alaska Medicaid
Xerox
05.2014 - 11.2014
Cytoprep Technician II
Quest Diagnostic Medical Laboratories
09.2001 - 05.2013
Associate of Arts - Liberal Arts
Central New Mexico Community College
Certificate - Health Wellness And Public Safety
Central New Mexico Community College
Associate of Science - Applied Science
Central New Mexico Community College
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