Summary
Overview
Work History
Education
Skills
Affiliations
Timeline
Generic
Michelle McQueen

Michelle McQueen

Dagsboro,DE

Summary

Seasoned Medical Insurance Specialist with excellent planning and problem solving abilities. Offering 25 years of experience and a willingness to take on any challenge. Organized, driven and adaptable professional with successful history managing high caseloads in fast-paced environments. Friendly Insurance Verification Specialist promoting a background in keeping sensitive patient data confidential while maintaining knowledge of Medicaid and private policy benefits. Possessing great relationship building and communication skills. Looking to tackle new challenges with a company that values dynamic skills and a strong work ethic. Highly-motivated employee with desire to take on new challenges. Strong worth ethic, adaptability and exceptional interpersonal skills. Adept at working effectively unsupervised and quickly mastering new skills. Hardworking employee with customer service, multitasking and time management abilities. Devoted to giving every customer a positive and memorable experience. Committed job seeker with a history of meeting company needs with consistent and organized practices. Skilled in working under pressure and adapting to new situations and challenges to best enhance the organizational brand. Organized and motivated employee eager to apply time management and organizational skills in various environments. Seeking entry-level opportunities to expand skills while facilitating company growth.

Overview

35
35
years of professional experience

Work History

Grievance Appeals Specialist

EmblemHealth
New York, NY
01.1989 - Current
  • Research complaints (grievances) and log and track the information as it moves through the clinical process or is tasked through internal contacts.
  • Contact customers to collect information and communicate disposition of the case, document all interactions.
  • Review cases to determine if it needs further review by a clinician.
  • Use sound, fact-based decision-making skills to render a decision for non-clinical complaints.
  • Use appropriate templates to complete necessary documentation for final appeals or grievance determination.
  • Relay appeal or grievance information to members, providers, and internal/external parties within the appropriate timeframe.

Senior Medical Claim Adjuster

EmblemHealth
New York, NY
05.2016 - 12.2019
  • Evaluate correspondence/inquiries to determine if requests meet criteria for adjustment.
  • Process full adjudications for all correspondence/inquiries which require adjustments, ALGS letter generation and exceptions resolution.
  • Evaluate correspondence/requires determination of correctness and accuracy of payment.
  • Evaluate inquires from internal EmblemHealth departments on behalf of members and providers as well as correspondence.

Senior Clerk OCR (optical Character Recognition)

EmblemHealth
New York, NY
10.2000 - 02.2016
  • Review scanned images rejected and determines reason and processed
  • Performed reject repair, data entry and data validation on images in a batch.
  • Verifies and/or make corrections concerning document information as necessary.
  • Provided administrative support.

Transporation Security Officer (TSA)

TSA
Jamaica
10.2011 - 06.2015
  • Screened passengers and luggage for unauthorized objects prior to boarding flight utilizing manual searches, metal detector, explosive trace detection, x-ray devices,
  • Identified potential security breach by observation of travelers and scrutinizing tickets and printed information.

Claims Approver Senior Business Unit, High Dollar

Group Health Incorporated
New York, NY
09.1992 - 10.2000
  • Entered claims using GHI Coding guidelines, into medical claim system
  • Resolved all certification edits utilizing GHI desktop procedures during edit resolution.
  • Evaluated medical claims that were suspended within the Medical Claim system utilizing GHI coding and exception desktop procedures during edit resolution
  • Corrected claim as required for settlement utilizing established policies, and procedures.
  • Followed guidelines interpreting contract files in order to enter, evaluate and approve medial claims.

Coding Claims Operation

Group Health Incorporated
New York, NY
01.1989 - 09.1992
  • Directly entered pertinent processing data in the medical/hospital claims mainframe system
  • Applied training, policies and procedures evaluating and correcting edits received through entry and finalized each claim
  • Followed guidelines identifying claims that were misdirected in normal daily workflow
  • Perform other related duties as assigned

Education

Some College (No Degree) - Basic Accounting And Recordkeeping, Data Process

Blake Business School
New York, NY

Skills

  • Workflow Management
  • Objective Evaluation
  • Policy Knowledge
  • Legal Research
  • Issue Identification
  • Insurance Policies Understanding
  • Appeals Process Proficiency
  • HIPAA Compliance Knowledge
  • Strong analytical skills
  • Effective communication abilities
  • Problem-solving capabilities
  • Medical Terminology Familiarity
  • Insurance Claim Forms Review
  • Customer Service
  • Data Entry
  • Claim Amount Calculations
  • Teamwork and Collaboration
  • Information Verification
  • Financial Transactions
  • Insurance terminology
  • Team Collaboration
  • Background in insurance
  • Adaptability and Flexibility
  • Data transcription
  • Multitasking
  • Interpersonal Communication
  • Payment and Investigation Escalations
  • Attention to Detail
  • Paperwork Processing
  • Decision-Making
  • Understanding of medical terms
  • Time management abilities
  • Medical Terminology
  • Insurance Coverage Verification
  • Problem-solving aptitude
  • Recordkeeping Organization
  • Outstanding clerical abilities

Affiliations

New York Guard

State Military

Timeline

Senior Medical Claim Adjuster

EmblemHealth
05.2016 - 12.2019

Transporation Security Officer (TSA)

TSA
10.2011 - 06.2015

Senior Clerk OCR (optical Character Recognition)

EmblemHealth
10.2000 - 02.2016

Claims Approver Senior Business Unit, High Dollar

Group Health Incorporated
09.1992 - 10.2000

Grievance Appeals Specialist

EmblemHealth
01.1989 - Current

Coding Claims Operation

Group Health Incorporated
01.1989 - 09.1992

Some College (No Degree) - Basic Accounting And Recordkeeping, Data Process

Blake Business School
Michelle McQueen