MICHELLE JACOBS
Sr. Claims Analyst
Arlington,TX
Summary
Medicare Compliance Analyst seeking a long-term career within a reputable organization. Possessing 30 years of health insurance experience, 12 of those years in Medicare Advantage. I am eager to apply my comprehensive background to ensuring organizational success.
Overview
31
31
years of professional experience
Work History
Claims Sr. Analyst
Southwestern Health Resources
Farmers Branch, Texas
01.2021 - Current
- Review High Dollar Claims
- Create Data Reports
- Financial Impact Reports
- Review for Claims Accuracy
- Provider Inquiries & Verifications
- Assist in creating P&P's
- Daily Projects
- Confirm System Setups
- Testing for Configuration Setups
- Review for Authorizations
- Review for Accuracy in Contracts Setup in System
- Performed Target Claims Audits
- Monthly monitoring of MAPD PYMT C ODAG Universe for timeliness and accuracy within current CMS Audit Protocols
Medicare Advantage Compliance Analyst
Mutual of Omaha
Omaha, Nebraska
03.2019 - 12.2020
- Monthly review of MAPD & PDP Enrollment Data Validation
- Monthly monitoring of all MAPD ODAG & CDAG Universes for timeliness and accuracy within the current CMS Audit Protocols
- Tracking of Grievances and Medicare CTMs for trending Issues
- Screening employees and vendors against the Federal Exclusion List with the Office of the Inspector General
- Oversee the required Medicare Compliance Training for all employees are completed within the Medicare required timeline
- Assist VP of Compliance with data for Compliance Committee presentations
- Review and approve all Member Communications for compliance with CMS Model Guidance
- Weekly & Bi-weekly meetings with delegates to ensure effective oversight of the Delegated First Tier Entities
Corporate Compliance Auditor
NTSP
Fort Worth, Texas
07.2016 - 03.2019
- Audit TPA Medicare Claims
- Meeting Minutes
- Identify Trending Issues by Examiner
- Report Configuration Issues
- Training Presentations
- New Hire Orientation Presentations
- Random Audits
- Medicare Audit Prepping
- Corrective Action Spreadsheets
- Organize Meetings for Compliance VP
- Prepare for Compliance Week
- Create and Distribute Monthly Audit Reports
Claims Auditor
SILVERBACK TPA
Fort Worth, Texas
07.2013 - 07.2016
- Audit Medicare Claims
- Review Daily Checks for accuracy
- Data Entry Reviews
- Random Processor Audits
- Adjust Claim Payments & Check Voids
- Create and Distribute Monthly Audit Reports
- Audit Auto Adjudicated Claims
- Approve correspondence to Providers
Claims Risk Examiner III
HEALTHMARKETS
North Richland Hills, Texas
11.1993 - 02.2012
- Processing medical claims while maintaining quality / production goals
- Adjust Monies & Claims
- Reviewed high dollar medical claims, exceeding $20,000
- Released high dollar medical claims with a $50,000 limit
- Confirmed contract compliance with all claims
- Ensured PPO discounts were applied according to contract agreements
- Over limit - Pay-hold Audits
- Policy interpretations
- Confirmed state and mandated benefits
- Approved correspondence to Insured's and Providers
- Assured documentation of all investigations
Education
Associate of Applied Science - Business Administration
Tarrant County College
Hurst, Texas06.1993
Skills
- PC literate
- Microsoft Office products
- Medical Terminology
- CPT coding
- HCPCs coding
- ICD-10 coding
- Facets Claims Operating System
- QNXT Claims Operating System
- Excellent oral communication skills
- Excellent written communication skills
- Dependable
- Trustworthy
- Effective analytical skills
- Effective interpretive skills
- Customer Service oriented
- Strong organizational skills
- Good interpersonal skills
- Quality driven
- Meet or exceed performance expectations
- Work well under pressure
- Work with limited supervision
- Thrive in a Team Environment
References
References available upon request.
Timeline
Claims Sr. Analyst
Southwestern Health Resources
01.2021 - Current
Medicare Advantage Compliance Analyst
Mutual of Omaha
03.2019 - 12.2020
Corporate Compliance Auditor
NTSP
07.2016 - 03.2019
Claims Auditor
SILVERBACK TPA
07.2013 - 07.2016
Claims Risk Examiner III
HEALTHMARKETS
11.1993 - 02.2012
Associate of Applied Science - Business Administration
Tarrant County College
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