Natasha Hughes
Richmond,TX
Summary
Committed job seeker with a history of meeting company needs with consistent and organized practices. Skilled in working under pressure and adapting to new situations and challenges to best enhance the organizational brand.
Overview
16
16
years of professional experience
Work History
Claims Examiner Senior
Texas Children's Health Plan
Houston, TX
05.2022 - 05.2024
- Accountable for reviewing adjudication software system's claim and line item edits to decide whether to pay claim/line item(s)
- Familiar with ICD 9 and ICD 10 diagnosis codes, CPT and Rev codes
- Provide support, coaching and mentoring to other team members, as needed
- Prepare timely and appropriate file reviews, per departmental guidelines.
- Performed data entry into the computer system to record information regarding claim status.
- Reviewed medical records and documents to determine coverage eligibility of claims for insurance benefits.
- Investigated discrepancies in claims and resolved issues with customers via telephone or written correspondence.
- Assessed accuracy of claim payments by comparing submitted bills to benefit allowance guidelines.
- Processed appeals from denied claims according to established procedures while ensuring compliance with applicable laws and regulations.
- Created reports on rejected claims, including statistical analysis of trends in rejections.
- Evaluated requests for pre-certification and authorization services, determining appropriate reimbursement levels based on contractual agreements between providers and payers.
- Researched complex billing errors that required an in-depth review of all available documentation before resolution could be reached.
- Maintained up-to-date knowledge about changes in healthcare reform legislation affecting provider reimbursements.
- Conducted audits of claim files to ensure adherence to departmental standards.
- Handled and processed variety of claims, including Inpatient,Outpatient, LSS , DRG and Specialty claims.
- Double-checked and reviewed documentation for denied and accepted insurance claims.
Claims Examiner
Texas Children's Health Plan
Houston, TX
05.2019 - 05.2022
- Efficiently investigate, evaluate, and manage all type of claims
- Communicate with claimants, providers and vendors regarding claims issues
- Input claims into the system for appropriate tracking and processing
- Reviewed policies to determine appropriate levels of coverage and assist with approval or denial decisions.
- Input claim information and payments into company database.
- Maintained thorough understanding of fraudulent and illegal practices.
- Gathered information from various third parties to determine claim acceptability.
- Investigated questionable claims to determine payment authorization.
- Reviewed claims to ensure accuracy, resulting in multiple claim reductions.
- Completed required investigations on referred files within established timeframes.
- Double-checked and reviewed documentation for denied and accepted insurance claims.
- Paid and processed claims within designated authority level.
- Managed workloads efficiently by prioritizing tasks based on urgency or importance.
Claims Examiner
HealthFirst
Houston, TX
05.2017 - 05.2019
- Reviewed medical records and documents to determine coverage eligibility of claims for insurance benefits.
- Performed data entry into the computer system to record information regarding claim status.
- Assessed accuracy of claim payments by comparing submitted bills to benefit allowance guidelines.
- Processed appeals from denied claims according to established procedures while ensuring compliance with applicable laws and regulations.
- Provided guidance to other staff members regarding claim processing rules and regulations.
- Researched complex billing errors that required an in-depth review of all available documentation before resolution could be reached.
Field agent
Beloved Home Health care
Houston, TX
12.2016 - 05.2017
- Collected information about conditions and treatment plans from caregivers, nurses, and doctors.
- Changed bed linens and maintained a clean living environment for the client's safety.
- Administered medications as instructed by physician or nurse practitioner.
- Reported any changes in the client's physical or emotional condition to supervisor immediately.
- Monitored vital signs such as temperature, pulse rate, blood pressure .
- Took initiative to ensure all tasks were completed efficiently within the designated time frame.
- Maintained clean and well-organized environment for client happiness and safety.
- Provided companionship and monitored health condition of clients.
- Transported clients to doctor appointments and social events.
- Prepared meals and snacks according to prescribed diets.
Assistant Site Coordinator
FBISD Extended Day
Sugarland, TX
08.2011 - 10.2014
- Maintaining a positive demeanor to facilitate a stable and consistent environment
- Maintaining accurate and detailed records
- Familiarizing parents and co-workers with curriculum, regulations and centers policies.
- Assisted with the coordination of daily operations of a site, including staffing and scheduling.
- Organized and coordinated events such as conferences, meetings, workshops or training sessions.
- Provided guidance to young children on how to interact with others in a positive manner.
- Encouraged children to develop social skills by participating in group activities.
- Interacted with parents and guardians about their child's progress at the afterschool program.
- Maintained accurate records of attendance and other information related to each child's participation in the program.
- Ensured that all materials used were age-appropriate for each student's level of development.
- Developed lesson plans based on curriculum requirements, individual needs, interests, and abilities of students.
- Worked with staff members to plan field trips or other offsite activities for the students.
- Communicated with parents about daily activities and any concerning behaviors.
Overnight Cashier
CVS Pharmacy
Pearland, TX
05.2008 - 06.2010
- Maintaining a clean and presentable sales floor
- Recommending merchandise to customers based on their needs and preferences
- Responding to customer inquiries in a prompt and efficient manner.
- Adhered to all company policies and procedures related to cash handling practices.
- Communicated effectively with co-workers to ensure smooth operations during shift changes.
- Organized stockroom shelves to ensure easy access for customers looking for specific items.
- Greeted customers and provided friendly customer service.
- Accepted cash, check, credit card payments and calculated change due for customers.
- Maintained cleanliness of work area throughout shift.
- Stocked shelves with merchandise and ensured proper display according to company standards.
- Checked identification for customers purchasing age-restricted items.
- Assisted in resolving customer complaints in a professional manner.
- Answered customer inquiries regarding products or services offered by the store.
- Identified security risks and thefts and alerted management immediately.
- Provided excellent customer service through active listening and problem solving skills.
Education
High School Diploma -
Alvin High School
05.2007
Skills
- Verbal Communication
- Policy Interpretation
- Claims Processing
- Insurance knowledge
- Investigative skills
- Data Verification
- Multitasking
- Records Review
- Adaptability and Flexibility
- Proficient in QNXT, EPIC, Tapestry and MHS
Organizations And Activities
- Miracle Deliverance Temple
- Lasagna Love 2024
References
Professional Referencces
- Claims Supervisor - Ginger - (870) 562 - 3528
- Organizational Trainer - Annie - (225) 803 - 5128
- Claims Auditor - Novelva Brown - (504) 717 - 9051
- Claims Manager - Guy Fraiser - (832) 417 - 0738
Personal References
- Close Friend - Daniel Reux - (832) 855 - 2108
- Close friend - Tremeka tingle - (832) 425 - 4710
Timeline
Claims Examiner Senior
Texas Children's Health Plan
05.2022 - 05.2024
Claims Examiner
Texas Children's Health Plan
05.2019 - 05.2022
Claims Examiner
HealthFirst
05.2017 - 05.2019
Field agent
Beloved Home Health care
12.2016 - 05.2017
Assistant Site Coordinator
FBISD Extended Day
08.2011 - 10.2014
Overnight Cashier
CVS Pharmacy
05.2008 - 06.2010
High School Diploma -
Alvin High School
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