Merlandy Watford
New Market
Summary
Professional and prepared for role, bringing experience in medical claims review and analysis. Skilled in claims adjudication, compliance verification, and problem-solving with strong focus on team collaboration and achieving outcomes. Reliable and adaptable in dynamic environments, consistently demonstrating thoroughness and integrity. Proficient in medical coding, regulatory requirements, and effective communication.
Overview
13
13
years of professional experience
Work History
Medical Claims Examiner
Florida Blue - Blue Cross Blue Shield Of Florida
01.2024 - Current
- Assisted in reviewing medical claims for accuracy and completeness.
- Learned to evaluate documentation against policy guidelines and coverage criteria.
- Supported the processing of claims using industry-standard software tools.
- Collaborated with team members to resolve claim discrepancies effectively.
- Adapted quickly to changes in procedures and technology in fast-paced environment.
- Enhanced claim processing efficiency by conducting thorough investigations and maintaining accurate documentation.
- Improved interdepartmental communication by fostering a collaborative environment and sharing vital information regarding complex cases.
- . Achieved excellent outcomes for both patients and healthcare providers by applying sound judgment in adjudicating complex medical claims.
Fraud Analyst
Velera (formerly PSCU)
04.2020 - 01.2024
- Analyzed transaction data to identify fraudulent activity and mitigate risks.
- Collaborated with cross-functional teams to enhance fraud detection processes.
- Conducted thorough investigations into suspicious accounts and transactions.
- Developed and implemented strategies to reduce false positives in fraud detection systems.
- Mentored junior analysts on best practices for fraud investigation techniques.
- Led initiatives to improve operational efficiency within the fraud analysis department.
- Analyzed large amounts of data to find patterns of fraud and anomalies.
- Tracked fraud cases and monitored trends to develop strategies for prevention.
- Performed risk assessments to determine level of fraud risk and prioritize investigations.
- Reduced fraud losses by implementing effective fraud prevention strategies and monitoring systems.
Life Enrichment Manager
Verve Senior Living
11.2016 - 04.2020
- Managed budgets for activity supplies and equipment, optimizing resource allocation while maintaining high-quality experiences for residents.
- Contributed to marketing efforts showcasing the facility''s robust activity offerings, attracting new residents by highlighting the vibrant community environment.
- Ensured compliance with state regulations governing activities in senior living facilities, safeguarding both resident safety and organizational reputation.
- Mentored staff members in best practices for life enrichment programming, fostering a supportive team environment focused on providing exceptional service.
- Delivered empathetic support to residents facing challenging life transitions, providing guidance and resources to navigate difficult situations successfully.
- Cultivated a vibrant atmosphere within the community by decorating common areas seasonally and organizing special themed events throughout the year.
- Established partnerships with local organizations, broadening available resources and opportunities for residents.
- Evaluated the effectiveness of programs by tracking participation levels and gathering resident feedback, refining offerings based on results.
Clerical Administrator
St. Michael's Hospital
01.2012 - 10.2016
- Managed daily scheduling for medical staff, optimizing workflow and ensuring patient care continuity.
- Coordinated interdepartmental communications, enhancing collaboration and reducing response times.
- Developed and maintained electronic filing systems, improving document retrieval efficiency by streamlining processes.
- Assisted in training new administrative staff, fostering a supportive learning environment and promoting team cohesion.
- Implemented process improvements that increased office productivity by standardizing administrative procedures.
- Ensured compliance with hospital policies by conducting regular audits of administrative practices and records management.
- Served as a reliable point of contact for clients and customers, providing exceptional service while addressing their needs efficiently.
- Organized company events, ensuring seamless execution from planning through completion.
- Increased productivity by prioritizing tasks and multitasking effectively in a fast-paced environment.
Education
David & Mary Thomson Collegiate Institute
Toronto, CanadaBachelor of Science -
University of Toronto
Toronto, CanadaSkills
- Customer service focus
- Claims processing proficiency
- HIPAA compliance
- Teamwork orientation
- Quality assurance checks
- Thorough claims reviews
- Critical Decision-making
- Teamwork and collaboration
- Problem-solving
- Time management
Timeline
Medical Claims Examiner
Florida Blue - Blue Cross Blue Shield Of Florida
01.2024 - Current
Fraud Analyst
Velera (formerly PSCU)
04.2020 - 01.2024
Life Enrichment Manager
Verve Senior Living
11.2016 - 04.2020
Clerical Administrator
St. Michael's Hospital
01.2012 - 10.2016
David & Mary Thomson Collegiate Institute
Bachelor of Science -
University of Toronto
Similar Profiles
Abdo TaressaAbdo Taressa
Customer Service Representative at Florida Blue - Blue Cross Blue Shield Of FloridaCustomer Service Representative at Florida Blue - Blue Cross Blue Shield Of Florida
Heath WesenbergHeath Wesenberg
Business Support Analyst II at Florida Blue - Blue Cross Blue Shield Of FloridaBusiness Support Analyst II at Florida Blue - Blue Cross Blue Shield Of Florida
Marquise MccullahMarquise Mccullah
Claims Adjuster at Florida Blue - Blue Cross Blue Shield Of FloridaClaims Adjuster at Florida Blue - Blue Cross Blue Shield Of Florida
Amber CappsAmber Capps
Family Service Worker at Youth VillagesFamily Service Worker at Youth Villages
Ramon RobinsonRamon Robinson
Electrician at Tradesource, IncElectrician at Tradesource, Inc