Nachez King
Overview
3
3
years of professional experience
Work History
Coordinator II, OPS Account
CVS Health Aetna
09.2024 - Current
- Validate claims associated with refund checks including but not limited to, Contract Errors, COB Calculations, Billed in Error, and Corrected Claims, to determine if they are overpaid based on Aetna Policy and guidelines.
- Request overpayment related information, via phone calls or emails to providers or members.
- Create and send letters to external constituents.
- Support the PIAB Overpayment Recovery Department in a production and quality environment.
Claims Benefit Specialist Ops
CVS Health
01.2023 - Current
- Reviews and adjudicates routine claims in accordance with claim processing guidelines.
- Analyzes and approves routine claims that cannot be auto adjudicated.
- Applies medical necessity guidelines, determines coverage, complete eligibly verification, identify discrepancies and applies all cost containment measures to assist in the claim adjudication process.
- Coordinates responses for routine phone inquiries and written correspondence related to claim processing issues.
- Proofs claim or referral submission to determine, review or apply appropriate guidelines, coding, member identification process, diagnosis and pre-coding requirements.
- Facilitate trainings as team subject matter expert(SME).
- In accordance with prescribed operational guidelines, manages claims on desk, route/queues, and ECHS within specified turn-around-time parameters (Electronic correspondence Handling System - system used to process correspondence that is scanned in the system by a vendor).
- Utilizes all applicable system functions available ensuring accurate and timely claim processing services (i.e. utilizes claim check, reasonable and customary data, and other post-containment tools).
Education
High School Diploma -
CCNY
05-2018
Bachelor of Arts -
CCNY
05-2018
Skills
- Multitasking and organization
- Data entry
- Inventory management
- Decision-making
- Adaptability and flexibility
- Attention to detail
- MS office
- Team collaboration
Timeline
Coordinator II, OPS Account
CVS Health Aetna
09.2024 - Current
Claims Benefit Specialist Ops
CVS Health
01.2023 - Current
High School Diploma -
CCNY
Bachelor of Arts -
CCNY