Michelleann Wilson
Medical Claims Professional
Bear,USA
Summary
Accomplished and highly qualified Claims Adjuster with over five years of specialized experience in customer service and claims processing within the healthcare sector. Consistently delivers exceptional service and fosters strong relationships with users and providers. Proven track record in navigating complex clinical and medical terminology, adept at handling medical equipment and services, billing, coding procedures, and insurance verification with precision. Committed to enhancing operational efficiency and customer satisfaction through strategic problem-solving and effective communication. Dedicated to continuous professional development to remain up-to-date of industry trends and best practices.
Overview
25
25
years of professional experience
Work History
Sr. Coordinator Complaint and Appeals
Aetna Medicare
12.2024 - Current
- Managing reviewing and analyzing of over 150 appeals and grievances a month to identify trends and areas for improvement
- Communicate findings and recommendations to internal teams to drive quality improvement initiatives.
- Collaborate with cross-functional teams to develop and implement strategies for addressing identified issues.
- Ensure compliance with healthcare regulations and company policies.
- Conduct root cause analysis on identified issues and develop action plans to prevent future occurrences
- Utilize data analysis tools and techniques to track, report, and present data on grievances and appeals.
- Maintain accurate and detailed records of all activities and findings.
- Act as a subject matter expert on grievance and appeals processes and regulations.
- Communicate with members, providers, and other stakeholders to resolve issues and answer inquiries related to grievances and appeals.
- Coordinated cross-functional teams to streamline operational processes and enhance service delivery.
Senior Claim Resolution Specialist (Telecommuter)
UnitedHealth Group/ Optum-LHI
01.2021 - 03.2024
- Working with moderate to higher complexity claims within assigned authority limits.
- Using multiple software systems and claims best practices to determine next step, for claims that were not processed or rejected in auto-adjudication system.
- Uploading and correcting daily files in raw data state.
- Assisting phone team with escalated claim issues.
- Entering claims accurately and staying within the 30-day turnaround time.
- Reporting and working with other departments on any claim or system trends that effect claims processing.
Claims Adjuster (Telecommuter)
UnitedHealth Group
01.2016 - 01.2021
- Provide expertise and general claims support to teams in reviewing, researching, investigating, negotiating, processing and adjusting claims; authorizes payment or refers claims to investigators for further review.
- Reviews claims and completes complex research in multiple systems and reports to accurately calculate member’s adjustments according to their benefit plan.
- Adjusts voids and reopens claims on-line within guidelines to ensure proper adjudication.
- Review and make adjustments/corrections to processed claims through researching, investigating issues, making determination and communicating with member and management.
- Evaluated claims on average 30-60 claims daily for accuracy and compliance with policy guidelines.
- Collaborated with medical professionals to assess claim validity and gather necessary documentation.
Claims Representative (Telecommuter)
UnitedHealth Group
01.2011 - 01.2016
- Served as a Claims Representative overseeing the full range of provider relations and service interactions within UnitedHealth Group, including working on end-to-end provider claim and call quality, future service enhancements, and training & development of external provider education programs.
- Answered calls from members/providers regarding claims, eligibility and benefits regarding mental health benefits.
- Facilitated programs to build positive relationships between health care providers and practice managers.
- Implemented strategies related to the development and management of provider networks, identifying gaps in network composition and services to assist staff in prioritizing contracting needs.
Customer Service Specialist
ACS
01.2010 - 01.2011
- Answered inbound calls from full time employees, and retirees, to make elections for health and welfare coverage, and make changes to health and welfare benefits, during open enrollment periods.
- Responded to telephone or written correspondence inquiries from members and providers.
- Developed an understanding of customer needs and trends to improve customer satisfaction and loyalty.
- Evaluated all documents to ensure that appropriate information has been obtained for billing purposes.
- Communicated with insurance companies and/or prior authorization requests.
- Working knowledge of Cobra, Flex Spending Accounts, Healthcare Reform Changes, and Medicare guidelines.
Customer Service Specialist
Praxair Healthcare
01.2007 - 01.2008
Eligibility Specialist
ICT/Blue Cross Blue Shield
01.2006 - 01.2007
Customer Service Representative
AIG Insurance
01.2004 - 01.2006
Customer Service Representative
Advanced Staffing/Household Bank
01.2001 - 01.2003
Education
Medical Coding & Billing ICD-9/ICD-10 Certificate
Vision Training Systems
New Castle, DE01-2019
Medical Billing & Terminology Training
Dawn Training Center
New Castle, DE01-2017
Skills
- Project assistance
- Decision-making
- Database management
- Multitasking and organization
- Strategic planning
- Report writing
- Quality Customer Service
- Administrative Support
- Policy Claims Processing
- Medical Billing & Coding
- Client Relationship Building
- Excellent Communication Skills
- Conflict Resolution Skills
- Staff Training & Development
- Clinical & Medical Terminology
- Healthcare Database System
- Medicare/Medicaid Regulations
- HIPAA Compliance
- Information collection
- Workflow management
- Excel spreadsheets
- Microsoft Suite
- Iset
- Linx
- Cosmos
- Facets
- Mednet
- UMR portal
- ISET
Timeline
Sr. Coordinator Complaint and Appeals
Aetna Medicare
12.2024 - Current
Senior Claim Resolution Specialist (Telecommuter)
UnitedHealth Group/ Optum-LHI
01.2021 - 03.2024
Claims Adjuster (Telecommuter)
UnitedHealth Group
01.2016 - 01.2021
Claims Representative (Telecommuter)
UnitedHealth Group
01.2011 - 01.2016
Customer Service Specialist
ACS
01.2010 - 01.2011
Customer Service Specialist
Praxair Healthcare
01.2007 - 01.2008
Eligibility Specialist
ICT/Blue Cross Blue Shield
01.2006 - 01.2007
Customer Service Representative
AIG Insurance
01.2004 - 01.2006
Customer Service Representative
Advanced Staffing/Household Bank
01.2001 - 01.2003
Medical Coding & Billing ICD-9/ICD-10 Certificate
Vision Training Systems
Medical Billing & Terminology Training
Dawn Training Center