Miranda Pendleton
Lehi,UT
Summary
I am currently a Claim Settlement Specialist looking to expand my career and education within Select Health to continue helping our members live the best lives possible with my 12 years of experience.
Overview
12
12
years of professional experience
Work History
Claim Settlement Specialist
Select Health
04.2022 - Current
- Negotiates the financial settlement of non-participating provider and facility medical claims through evaluation of billed charges against other industry pricing models.
- Supports team members in resolving complex settlement issues, fostering a collaborative work environment.
- Implements the No Surprises Act process by reviewing open negotiation requests and responding in a timely manner
- Collaborates with the Claims Support Team to help with any excess workload while fostering a positive inter-departmental relationship.
- Maintains compliance with industry regulations through strict adherence to policies and procedures during the settlement process.
- Participates in the implementation of new systems and technology, ensuring seamless integration with existing processes and minimizing disruption to the workflow.
- Trained a group of 30+ on a new process to help reduce the call volume for our member services department.
Senior Claims Processor
Select Health
10.2019 - 04.2022
- Adjudicated claims with unique and high dollar amounts while using documentation and plan information to apply correct payments.
- Managed own time within a 40hr work week, as well as own timecard.
- helped as a claims examiner when needed by researching claims at a deeper lever to ensure they were payed correctly by a processor.
- Provided backup for claims processors and examiners. Supported other departments as needed
- Reviewed feedback from supervisors, trainers, auditors, and examiners which i would then identify and implement steps for improvement for quality member care
Health Benefits Specialist
Select Health
09.2012 - 10.2019
- Worked with members and providers to understand insurance coverage as well as claims processing and benefits
- Mentored numerous new hires while demonstrating our 'one and done' philosophy to help our members and providers.
- Managed one vendor relationship when we first started doing business with St. Luke's for the Center for Spine Wellness and helped to create the tracking process for these specific members.
- Successfully piloted working from home as one of about five people sent home to test it out.
- Took escalated and supervisor calls
- Managed multiple pods' questions while they were on calls and needed help.
Education
Some College -
Salt Lake Community College
Skills
- Quickly processes claims
- Identifies issues
- Excel
- AWD/Facets
- Time Management
- Teamwork
Personal Information
Title: Claim Settlement Specialist
Timeline
Claim Settlement Specialist
Select Health
04.2022 - Current
Senior Claims Processor
Select Health
10.2019 - 04.2022
Health Benefits Specialist
Select Health
09.2012 - 10.2019
Some College -
Salt Lake Community College
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