MICHELLE RYAN
AMBOY,NEW JERSEY
Summary
Twenty one years’ experience in the healthcare industry reviewing /processing claims, supervising a team of Quality Examiners (professional & hospital claims), and also performing quality claim audits. Experienced Claims Auditor with background in scrutinizing insurance claims for compliance and identifying discrepancies. Strengths include comprehensive understanding of auditing procedures, sharp analytical skills, and ability to interpret complex insurance documents accurately. Proven history of enhancing efficiency by improving audit processes and documenting findings effectively.
Overview
32
32
years of professional experience
Work History
Quality Claims Auditor
Smart Data Solutions
Eagan, MN
01.2022 - Current
- Responsible for performing quality audits for all work performed by our Claim Examiners on behalf of our clients including correspondence/adjustments
- Auditing the integrity and accuracy of claims adjudicated by the Claims Processing staff
- Ensure claims are processed according to the Clients’ Summary Plan Documents as well as Company’s Standard Operating Procedures/Claims guidelines
- Track, analyze, and report findings to Claim Examiners and department leadership by documenting clear and concise audit findings and deliver to Examiner for review
- Auditors must also meet standards for quality and daily production
- Capable of investigative and analytical research and demonstrating critical thinking and supports the department with other projects as needed
QUALITY CLAIMS AUDITOR
Qualcare A Cigna Company
Piscataway, NJ
01.2010 - 12.2021
- Company Overview: Qualcare/A Cigna Company 2000 to 2021
- Responsible for auditing the integrity and accuracy of claims adjudicated and by the Claims Processing staff
- Ensure claims are processed according to the Clients’ Summary Plan Documents as well as Company’s Standard Operating Procedures/Claims guidelines
- Perform statistically valid random audits on claims processed by the Claims Processing staff to confirm payment accuracy and completeness of data entry
- Provide daily/weekly feedback to examiners via systemic error sheets
- Calculate and issue monthly departmental and individual performance statistics
- Present monthly statistics on the top error trends
- Re-educate claims staff during monthly departmental meetings based on audit findings
- Complete assigned work on a regular basis
- Consistently achieve quality and production metrics
- Analyze monthly error trend reports
- Offer process improvements to strengthen internal controls and business performance
- Supports Operations and Company in achieving metrics and annual initiatives
- Performs quality audits for other functions as needed (example Plan Building)
- Supports department in other areas as needed
- Assisted in auditing for the Plan Building Team testing new plans, updates/changes to plans verifying that the system is hitting the correct benefits, and also taking the correct copay deductible, and coinsurance
- Helped to re-educate Examiners in areas of claim processing, following contracts, and client communication packets
- Qualcare/A Cigna Company 2000 to 2021
SUPERVISOR, CLAIMS
Qualcare A Cigna Company
Piscataway, NJ
01.2005 - 12.2010
- Company Overview: Qualcare/A Cigna Company 2000 to 2021
- Responsible for supervising and directing the activities for a team of Claims Processors in all areas regarding claims adjudication, to ensure professional, prompt and accurate claims processing
- Also, assists in resolving member, client and provider inquires
- Assists in hiring and training of new employees
- Recommends or initiates personnel actions such as promotions, transfers, discharges, and disciplinary measures
- Reviews time sheets for accuracy
- Approves time off requests
- Evaluate staff performance on an ongoing basis and is responsible for performance review process, progressive discipline to ensure a non-discriminatory and consistent work force
- Determines work procedures, work schedules, arranges relief, and expedites work flow, issues either oral or written instructions
- Assigns duties and examines work for conformance to policies and procedures
- Maintains harmony among workers and resolves grievances
- Accepts, reviews, and processes claims from plan members, physicians, hospitals and other health care providers
- Checks claims for accuracy, completeness, appropriateness of medical procedure for diagnosis and reasonableness of charge
- Supports Customer Service in responding to Member, Client and Provider inquires that are critical, difficult or irate regarding claims payments, adjusts errors
- Priced high dollar claims through Redbook using NDC, dosage and units
- Reviewed and processed all foreign claims using various software and tools for translation and currency
- Qualcare/A Cigna Company 2000 to 2021
Claims Examiner
QualCare
Piscataway, NJ
11.2000 - 12.2005
- Developed a detailed understanding of the company's policies and procedures related to claim processing and payment determination.
- Interacted with providers regarding claim status or other related issues as required.
- Inputted data into the system, maintaining accuracy of provider coding information and reported services.
- Maintained updated knowledge of changes in healthcare regulations impacting claims processing.
- Sent clinical request and missing information letters to obtain incomplete information.
- Determined the appropriate payment amount based on contractual agreements with providers.
- Input claim information and payments into company database.
- Verified insurance coverage and eligibility of patients for services rendered.
- Reviewed and processed medical claims for accuracy and completeness according to established guidelines.
- Performed data entry into the computer system to record information regarding claim status.
Billing Office Representative
South Amboy Medical Center
South Amboy, NJ
09.1996 - 05.2000
- Resolved customer disputes regarding billing issues.
- Enforced compliance with organizational policies and federal requirements regarding confidentiality.
- Answered customer questions to maintain high satisfaction levels.
- Collected, posted and managed patient account payments.
- Input statement information, reconciled accounts and resolved discrepancies.
- Gathered information to produce accounts payable reports for review.
- Maintained accurate records of all transactions related to billing activities.
- Performed data entry of payments received by patients or insurance companies.
Admitting/ER Registrar
South Amboy Medical Center
South Amboy, NJ
01.1993 - 09.1996
- Verified insurance coverage, collected co-pays, and completed paperwork associated with patient admissions.
- Transmitted medical records and other correspondence by mail, e-mail, or fax.
- Maintained an organized filing system of all patient records and documents.
- Received patient information and scheduled appointments for emergency room visits.
- Completed relevant insurance and other claim forms.
- Scheduled tests, lab work or x-rays for patients based on physician orders.
- Greeted patients upon arrival to the ER and provided them with necessary forms to complete.
- Arranged hospital admissions for patients as required.
- Assisted physicians in scheduling tests and treatments for patients as needed.
- Prepared reports, invoices, letters, or medical records using word processing, spreadsheet, or other software applications.
- Communicated effectively with other departments within the hospital to ensure smooth transition of care from ER to other units and departments.
- Greeted patients, determined purpose of visit and directed to appropriate staff.
- Adhered to HIPAA requirements to safeguard patient confidentiality.
- Performed clerical tasks such as scanning documents, photocopying, faxing reports.
- Answered telephones and directed calls to appropriate medical or administrative staff.
- Answered incoming calls regarding patient inquiries or concerns.
Education
High School Diploma -
Harold G. Hoffman High School
South Amboy, NJ06-1992
Skills
- Claims processing
- Pending claims follow up
- Policyholder request reviews
- Exemplary communication skills
- Payment analysis
- Accounting practices
- Benefits guidelines
- Overpayment identification
- Investigative skills
- Documentation review
Timeline
Quality Claims Auditor
Smart Data Solutions
01.2022 - Current
QUALITY CLAIMS AUDITOR
Qualcare A Cigna Company
01.2010 - 12.2021
SUPERVISOR, CLAIMS
Qualcare A Cigna Company
01.2005 - 12.2010
Claims Examiner
QualCare
11.2000 - 12.2005
Billing Office Representative
South Amboy Medical Center
09.1996 - 05.2000
Admitting/ER Registrar
South Amboy Medical Center
01.1993 - 09.1996
High School Diploma -
Harold G. Hoffman High School