Nina Gathe
Summary
Driven Claims Adjuster with extensive experience in claims processing and regulatory compliance. Demonstrates a strong ability to enhance operational efficiency and improve claims performance through meticulous coordination of benefits and resolution of disputes.
Overview
17
17
years of professional experience
Work History
Claims and Appeals Intake Coordinator Specialist
Wellcare
01.2024 - 05.2026
- Coordinated benefits appeals process for patients and providers, ensuring thorough review and resolution.
- Processed claims, handled the research and eligibility of the members from their plans and determined the correct payment information for the member and the provider.
- Confirm patient eligibility of insurance coverage for their services, using multiple host systems and portals.
- Performed the benefit verification process through the patients insurance plans including documenting the patients coverage.
- Documented coinsurance, copay, deductibles, and authorizations for accurate claims processing.
- Initiated follow-up and secured prior authorizations.
- Review disputed self-pay accounts.
- Calls to various payers to confirm eligibility, if a claim is on file and timely filing.
- Review host systems, add coverage, and electronically bill the claims once the information is verified.
- Handled predeterminations and medical reviews for patients.
- Utilized EPIC and Cisco systems for efficient workflow management.
Insurance Verification Specialist
Walgreens
03.2019 - 05.2024
- Accurately identifies and assigns payer plans in the electronic medical record and notifies appropriate leaders of potential payer or RTE discrepancies in the system.
- Utilized online systems, phone communication, and other resources to determine eligibility and benefits before date of service.
- Communicates with patients, clinicians, front-end staff, and translators to obtain any necessary additional or missing insurance or referral information.
- Coordinates benefits by effectively determining primary and secondary liability when needed.
- Reviews Medicare accounts for completed and accurate Medicare Secondary Payer Questionnaire (MSPQ) to ensure correct filing order for the visit.
- Notified physician offices and patients of issues with verifying insurance or meeting referral requirements.
- Demonstrated proficiency in understanding insurance terminology used in patient care.
- Maintained strict confidentiality while handling patient charts, records, and registration information.
- Assists in training new insurance verification staff and front-end staff on insurance verification processes.
- Executed additional tasks to support departmental operations.
Claims Research Analyst
Bristol Myers Squibb
08.2015 - 11.2020
- Experience for 5+ years in claims analysis and processing with expertise in state government programs such as Medicare and Medicaid.
- Improved claims performance by ensuring accurate and timely processing of claims.
- Reduced rework by identifying and remediating claims processing issues, interpreting claims-related regulatory and contractual requirements, and tailoring existing reports and data to meet project needs.
- Evaluates claims using standard principles and applicable state-specific regulations to identify claims processing errors.
- Identifies claims requiring reprocessing or readjudication in a timely manner to ensure compliance.
- Applies claims processing and technical knowledge to appropriately define a path for short/long-term systematic or operational fixes.
- Recommended updates to claims standard operating procedures (SOPs) and job aids, enhancing quality and efficiency of claims processing.
- Working collaboratively with internal/external stakeholders to define claims requirements.
- Utilized effective verbal and written communication skills to enhance team collaboration and project clarity.
- Applied knowledge of claims processing for inpatient and outpatient services within Medicare and Medicaid programs.
Customer Service Support Specialist
Enterprise Rental Car
03.2016 - 11.2019
- Responded to inbound phone calls and addressed customer concerns promptly and efficiently.
- Managed customer roadside assistance needs effectively.
- Provided support for customers with vehicle roadside rental assistance through insurance and personal avenues.
- Troubleshot website issues and vehicle component inquiries for customers.
- Offered product support about the vehicles and features on the vehicles for the customers with clear guidance to assist.
- Maintained clear, courteous, and professional communication to support customers.
- Processed customer documentation accurately to ensure proper record-keeping.
Patient Access Rep- Scheduling
03.2009 - 11.2016
- Managed scheduling of patient appointments for over 7 years, optimizing clinical resources and maximizing patient time efficiency.
- Resolved scheduling hurdles and provided clear, empathetic guidance to patients on pre-service requirements.
- Supported insurance authorization process, facilitating timely patient care access.
- Captured demographic and insurance information at checkout to facilitate a smooth billing process.
Education
bachelors degree - Business Management
Southern New Hampshire
Manchester, New Hampshire05-2024
Skills
- Claims Evaluation
- Insurance
- Regulatory compliance
- Data Analysis
- Project Management
- Time management
- Multi-Tasking
- Communication
References
Available upon request.
Awards
- Leadership of the month
- Supervisor Exceeds
- Employee of the month
Timeline
Claims and Appeals Intake Coordinator Specialist
Wellcare
01.2024 - 05.2026
Insurance Verification Specialist
Walgreens
03.2019 - 05.2024
Customer Service Support Specialist
Enterprise Rental Car
03.2016 - 11.2019
Claims Research Analyst
Bristol Myers Squibb
08.2015 - 11.2020
Patient Access Rep- Scheduling
03.2009 - 11.2016
bachelors degree - Business Management
Southern New Hampshire