MELINDA RAVENELL
Yonkers,NY
Summary
Lead Claims Analyst with extensive experience working with a major health care organization in the automation of claims for medical, hospital & dental claims recycles. Experienced at collaborating with other departments with focus on saving money, protecting integrity and reducing turmoil. Problem solving through creative and practical solutions with quantifiable cost savings. Over 30 years of professional and management experience in the Health Care Insurance Industry. 22 years of expertise assessing coverage and overseeing claims review. Leverages well-developed communication skills to deliver information to policyholders.
Overview
23
23
years of professional experience
Work History
Lead Claims Analyst
Cognizant Technologies Solutions
05.2017 - Current
- Participated in ongoing training programs to stay current on industry developments and maintain a strong understanding of relevant laws and regulations affecting the claims process.
- Responsible for all Medical, Hospital & Dental Claims Mass Adjustments Recycles
- Led cross-functional teams to analyze and understand the operational impacts and opportunities of technology changes
- Documented process flows and developed requirements for functional improvements and enhancements
- Conducted activity-based analysis of business processes and made recommendations bas
- Perform the lead role in conducting Claims Reconciliation file and develop Analysis summary reports and external communications for transmission to providers and vendors
- Direct multiple projects, tracking timelines of projects and ensuring that all phrases of the project are completed
- Proactively create template for utilization of other facilities submission of inquiries to ensure uniformity
- Acts as a liaison and as a subject matter expert between the business partners, IT, Claims Operations and Contracting in analyzing current processes and determining changes needed for new or modified processes and procedures relating to facility pricing reimbursement.
- Maintained strict confidentiality with all personal data as per company guidelines.
- Managed high-volume caseloads, prioritizing tasks to ensure timely completion of all claims.
- Maintained compliance with industry regulations and company policies while managing sensitive client information and claims records.
- Demonstrated a high level of accuracy and attention to detail in reviewing claim documentation for approval or denial decisions.
- Enhanced customer satisfaction by resolving complex claims issues in a timely manner.
- Interacted with clients and employees, which helped cultivate positive working relationships.
- Conducted thorough investigations into each claim, gathering relevant data and documentation to support decision-making processes.
- Reduced claims processing time by implementing efficient analytical techniques and strategies.
- Streamlined workflow processes for improved efficiency and reduced claim resolution times.
- Supported internal audit initiatives by providing detailed documentation of claims handling procedures as required for compliance purposes.
- Collaborated with cross-functional teams to develop best practices for claim handling procedures.
- Developed comprehensive reports for management review, highlighting key metrics related to claim volume, processing times, and settlement amounts.
EDI Specialist
EmblemHealth inc.
02.2006 - 07.2010
- Implement process for changes in policies and procedures to improve departmental functions, including HIPAA, Medicare Part A/B crossover transactions to now include COBA transactions
- Member of the HIPAA compliance team for electronic claim submission systems on time and on budget (including providers and vendors for HIPAA transactions and code sets)
- Centrally track, analyze trends, and report on all EDI issues, and identify root causes to improve daily operations
- Target high volume providers, conduct telemarketing calls and site visits, and attend seminars to promote EDI transactions and services
- Perform support/testing for providers and vendors to ensure receipt of EDI claims
- Work with trading partners to determine requirements for implementing new EDI documents or updates
- Troubleshooting and facilitating the resolution of any identified date file transmission and transaction errors through verification that all communication links and interfaces are working correctly and communicating appropriately.
EDI Technical Representative
Group Health Inc.
01.2001 - 02.2006
- Perform support for EDI trading partners for HIPAA transactions such as eligibility (ANSI 834), claims submission (ANSI 837), and claim remittance advice (ANSI 835)
- Troubleshooting support and analysis for network clients, vendors, and billing services and technical assistance
- Maintain and compile daily/weekly/monthly statistical reports for senior management
- Interface with Medicare carriers relating to claims issues, EDI file submissions, and HIPAA code sets
- Monitor, and analyze, execute and report all products daily job runs in Power builder software
- Work with EDI vendors to manage high volume submitters, proactively identify changes in submitter's volumes/pattern.
Lead Claims Analyst
EmblemHealth
07.2010 - 05.2017
- Maintained strict confidentiality with all personal data as per company guidelines.
- Managed high-volume caseloads, prioritizing tasks to ensure timely completion of all claims.
- Maintained compliance with industry regulations and company policies while managing sensitive client information and claims records.
- Demonstrated a high level of accuracy and attention to detail in reviewing claim documentation for approval or denial decisions.
- Enhanced customer satisfaction by resolving complex claims issues in a timely manner.
- Interacted with clients and employees, which helped cultivate positive working relationships.
- Conducted thorough investigations into each claim, gathering relevant data and documentation to support decision-making processes.
- Reduced claims processing time by implementing efficient analytical techniques and strategies.
- Maintained strong working relationships with third-party vendors, such as independent adjusters and appraisers, to facilitate prompt resolution of claims.
- Provided exceptional customer service by promptly addressing inquiries from policyholders, agents, and other stakeholders regarding the status of their claims.
Education
Networking -
Xincon Technical School
New York, NY01.2002
Business Management -
Hostos Community School
Bronx, NY01.1989
Business Management -
Mercer University
Norcross, GA01.1987
Skills
- Microsoft Word & Excel
- Flexible team player who thrives in environments requiring ability to effectively prioritize and juggle multiple concurrent projects
- Results-driven achiever with exemplary planning and organizational skills, along with a high degree of detail orientation
- Resourceful team player who excels at building trusting relationships with customers
- Productive worker with solid work ethic who exerts optimal effort in successfully completing tasks
- Internal and external customer service
- Claims analysis
- Interpersonal and written communication
- Policy Interpretation
- Proficient in Excel
- Document workflow
- Claim investigation
- Computer Skills
- Decision-Making
- Team Leadership
- Team Collaboration
- Healthcare Common Procedures Coding System (HCPCS)
- Database Management
Timeline
Lead Claims Analyst
Cognizant Technologies Solutions
05.2017 - Current
Lead Claims Analyst
EmblemHealth
07.2010 - 05.2017
EDI Specialist
EmblemHealth inc.
02.2006 - 07.2010
EDI Technical Representative
Group Health Inc.
01.2001 - 02.2006
Networking -
Xincon Technical School
Business Management -
Hostos Community School
Business Management -
Mercer University