Summary
Overview
Work History
Education
Skills
Timeline
Generic

Michelle Watts

Cotulla,TX

Summary

  • Hardworking and reliable, Detail-oriented Stop Loss Analyst with over 3.5 years of experience and 10 years in the healthcare insurance sector. Proficient in evaluating Stop Loss insurance claims, assessing high-dollar claims, and identifying potential Stop Loss claims. Possesses a strong background in regulatory compliance and underwriting processes. Skilled in collaborating with cross-functional teams to optimize timely claims filing and reimbursements. Committed to providing high-quality insights and recommendations to support decision-making and growth. Known for a strong work ethic and unwavering dedication, I thrive in collaborative environments, effectively enhancing claims management and overall performance. Hardworking
  • Consistency: meet or exceed deadlines, maintaining high productivity levels
  • Proactiveness: take initiative to tackle challenges without waiting to be asked
  • Willingness: voluntarily offer to assist in additional projects or tasks when needed
  • Adaptability: work efficiently under pressure or in changing environments
  • Fair Decision Making: ensure all actions and decisions respect company policies and values
  • Accountability: own up to mistakes and take responsibility for rectifying them
  • Respect: treat colleagues, clients and partners with fairness and dignity

Overview

17
17
years of professional experience

Work History

Medical Office

North Lamar Chiropractic
08.2015
  • Verified Insurance, Scheduled appointments, answer phones, take messages, billing
  • Follow-ups and data entry
  • Contact Patients Health care Insurance to verify Eligibility and Benefits
  • Assist with properly code services, procedures, diagnosis and treatments

Medical Office

Central Austin Family Medicine
08.2015
  • Verify Insurance, posted payments, enter patient's demographics, assist with verification of insurance, and assisted with medical office duties, follow up with patients opened accounts
  • Bilingual, Support, Exceptional customer service, communication, and rapport building skills
  • Currently trained in CPT, ICD-9, ICD-10 and HCPS coding with an emphasis usage and Business Communications, Multitask, phone answering
  • Able to grasp new concepts and implement them quickly.

Stop Loss Analyst

05.2021 - Current
  • Maintain a process for identifying potential specific claimants within each client’s utilization data, collaborating with key departments to monitor these claimants in a timely manner
  • Manage specific and aggregate claim submission processes, serving as a liaison between brokers, clients, billing entities, and Stop Loss carriers
  • Request changes to the Stop Loss policy and/or client SPD as necessary to ensure seamless coverage
  • Actively participate in team and department meetings regarding the Stop Loss process and any changes to planning as it relates to Stop Loss management
  • Perform other projects, assignments, and duties as assigned by management
  • Processes claims accurately, efficiently and within production requirements as well as split claims for stop loss purposes
  • Attention to detail and a strong work ethic
  • Ability to access and utilize research tools for accurate claims entry
  • Ability to read and understand contracts - Reinsurance contracts and Summary Plan Descriptions (SPD)
  • Runs both monthly and renewal reports from BI as well as other reports to assist with both Aggregate and Specific stop loss filings
  • Accurate and timely notifications of Trigger Diagnosis and 50% of specific deductible to stop loss carriers
  • Reviews pre-authorizations for notification purposes
  • Runs individual Specific Analysis (ISA) and other stop loss reports for review of potential stop loss notifications and filings
  • Files stop loss claims - initial, subsequent and/or final filings, making sure all necessary documentation is included and submitted in a timely manner
  • Reviews accuracy of claims included with reimbursement requests to prevent additional delay once the reinsurance claim has been received by the carrier
  • Knowledge of advance funded claims
  • Assists in training/mentoring of other employees at the Supervisor or Manager’s request to ensure consistency within the stop loss department
  • Assists in training/mentoring of other employees at the Supervisor or Manager’s request to ensure consistency within the stop loss department.

Member Advocate

BevCap, Boon-Chapman Administrators
11.2018 - 05.2021
  • My current position with Boon Chapman is a BevCap Member Advocate, providing
  • Outstanding service(s) to the clients and members
  • Assisting members with understanding their benefits and/or resolve claim issues
  • My goals as a member advocate is to build trusting relationships with the members and clients
  • Research and resolve customer service inquires by reaching out departmentally and then follow up until the resolution has been completed as well as answers
  • Member/group questions
  • Make outbound calls daily to achieve resolution of inquiries while maintaining outstanding service
  • Working knowledge of Company Portal such as El Dorado, Insight and Windows
  • Research claims in depth while maintaining outstanding service
  • Resolves provider/claim issues
  • Trend types of calls received and advise department or unit of possible issues
  • Finish all tasks and duties, adhering to deadlines to avoid deadlines

Account Manager/Analyst/Claims Manager, Bilingual Customer Service Rep /Benefit Specialist

Boon-Chapman Administrators
01.2018 - 11.2018
  • Answer a high volume of inbound calls and maintains a rapid response rate according to the agreed/standard metrics
  • Log information on calls received where required
  • Maintain effective relationships with co-workers, and supervisors, while
  • Displaying professionalism, efficiency, and courtesy
  • Maintain great customer service communications with providers and other
  • Departments
  • Research and resolve customer inquiries
  • Maintain files of correspondence, records and reports
  • Process returned mail, making updates to the system as needed
  • Prepare departmental reports for manager
  • Work with claims department and UR to Solve Claim and Precertification requests
  • Other duties as assigned

Intake Coordinator

Boon- Chapman Administrators
05.2016 - 01.2018

Direct Care Staff/ Transporter

Immigration Services, Favorite Healthcare Staffing, Inc
05.2014 - 01.2016
  • Childcare with immigration services, transporter, inventory, and assisted with other duties provide verbal and written communication Translator/Interpreter between sponsors ,and supervisors
  • Implementing safety protocols of child and program operations
  • Provide professional and confidential communication with the agency, the consumers family
  • Provided communication skills, and crises intervention techniques to help residents
  • Experiencing different type of emergencies
  • Assisted with other duties as assigned

Bilingual Intake Coordinator

01.2008 - 01.2015
  • Responsible for telephonic intake and documentation of initial precertification, claims review, and predetermination information received via telephone, fax or e-mail
  • Communicate employer plans precertification requirements, and verify status of precertification via telephone or fax
  • Primarily answers incoming calls to Prime Dx, based on call center standards
  • Review and complete the daily Intake Queue workflow
  • Document accurate notes of caller's information and return contact information
  • Assist with processing of all Prime Dx incoming and outgoing faxes
  • Transfer telephone calls to Utilization Review Nurse to receive clinical information
  • Document appropriate notes of caller's information and return contact information using Deer Walk Care Manager Software
  • Refer received fax or telephone clinical information to nurses to make a
  • Medical necessity determination of requested service
  • Verify and communicates employer group's precertification requirements
  • Data enter admission and referral events authorization after nurse's review
  • Verify and relays authorization information and status in Deer Walk Care Manager to callers via telephone or fax, and provides Prime Dx disclaimer
  • Direct and transfers appropriate calls to Boon Chapman's Customer Service
  • Department, Claims department, and to the Prime Dx Nurses for benefits, claims, and eligibility inquiries
  • Performs other tasks/duties as assigned including use of Excel and Outlook
  • Request clinical on pending/cases for review of medical necessity, Coursework included CPT, HCPCS and ICD 9-10 coding systems, medical insurance, knowledge in HIPAA & PHI's, emphasis of federal regulations and health records, processing of different types of insurance plans, understanding of Medicare, Medicaid and other state programs, processing of insurance claims, worker's compensation, disability income insurance and disability benefits programs.

Office Clerk

Watts Electric, Inc
06.2013 - 01.2014
  • Data entry, documentation, organize files, inventory, and assisted with clerical duties
  • Maintaining database by entering new and updated customer and account information
  • Transfers date from paper formats into computer

Education

CBCS Certification # N5P3R3S5: Medical Billing & Coding -

Southern Career Institute
Austin, TX
Oct 2016

Medical Billing & Coding Program -

Southern Careers Institute
Austin, TX

Skills

  • Administrative: Data Entry, Documenting, Answering phones, ICD/ CPT Coding, patient billing & Payment entry, insurance verification, medical terminology, filing and organization, skills in interpersonal and written communication, ability to multitask, ability to accurately compile data and perform detailed work, ability to meet deadlines, ability to maintain confidentiality of material and to maintain appearance and demeanor Customer Service:
  • Face-to-Face Etiquette, memo, and letter writing
  • Software: Electronic Medical records, Microsoft Word, Excel, Outlook, PowerPoint, Medical Portals, Filing Portals, El Dorado experience
  • Ringmaster Smart-LinQ Experience , sharepoint
  • Company Information Systems: Eligibility and Medical Claims
  • Ability to access, operate, and maintain various software applications
  • Ability to work independently with minimal supervision

Timeline

Stop Loss Analyst

05.2021 - Current

Member Advocate

BevCap, Boon-Chapman Administrators
11.2018 - 05.2021

Account Manager/Analyst/Claims Manager, Bilingual Customer Service Rep /Benefit Specialist

Boon-Chapman Administrators
01.2018 - 11.2018

Intake Coordinator

Boon- Chapman Administrators
05.2016 - 01.2018

Medical Office

North Lamar Chiropractic
08.2015

Medical Office

Central Austin Family Medicine
08.2015

Direct Care Staff/ Transporter

Immigration Services, Favorite Healthcare Staffing, Inc
05.2014 - 01.2016

Office Clerk

Watts Electric, Inc
06.2013 - 01.2014

Bilingual Intake Coordinator

01.2008 - 01.2015

CBCS Certification # N5P3R3S5: Medical Billing & Coding -

Southern Career Institute

Medical Billing & Coding Program -

Southern Careers Institute

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Michelle Watts