OMEKA BROOKs
Sacramento,CA
Summary
Business-minded Professional Claims Analyst with exemplary skills in customer service, time management and service coordination. Bringing over 3 years of related experience. Pursuing similar position with expanding insurance company.
Overview
21
21
years of professional experience
Work History
Professional Claims Analyst
Gainwell Technologies
05.2024 - Current
- Evaluate Dental Claims and Requests: Assess dental claims, adjustments, and prior authorization requests to ensure compliance with Medi-Cal Dental criteria and guidelines.
- Generate Information Requests: Create detailed requests for additional information from dental providers, ensuring all necessary claim details were accurately obtained.
- Ensure Documentation Completeness: Verified that all claim documentation is complete and in compliance with policy requirements, referring documents to dental professionals when necessary for further review.
- Data Analysis and Reporting: Analyze claim data trends to identify discrepancies, inaccuracies, or patterns requiring further investigation, and prepared detailed reports to support decision-making.
- Process Improvement Recommendations: Collaborate with team members to identify inefficiencies in the claims review process and provide actionable insights to streamline operations and improve overall accuracy.
- Compliance Monitoring: Regularly monitor changes in Medi-Cal Dental guidelines and ensure that internal processes are updated accordingly to maintain compliance and reduce claim denials.
- Team Coordination: Work closely with dental professionals and administrative staff to ensure that complex cases are resolved efficiently and within policy frameworks.
Quality Management Auditor
Delta Dental of California
06.2022 - 05.2024
- Run data reports from samples collected from the Medi-Cal Dental Services Division (MDSD) claim, Quality Management, and Treatment Authorization Request audit reports.
- Audit pre/post-adjudicated dental claims for accuracy per documented procedures and regulations.
- Audit correspondence for accuracy per documented procedures and regulations.
- Audit call center representative calls for accuracy per documented procedures and regulations.
- Determine the financial impact of errors identified.
- Conduct 2nd level analysis on the Quality Management team’s audits for call center representative calls and claims.
- Update quality control standards, methods, and procedures to meet compliance requirements.
- Provide data deliverables for external audit entities (for example - System and Organization Controls (SOC) audit).
Dental Auditor
Delta Dental of California
01.2019 - 06.2022
- Dup Tar specialty auditor- specializes in editing and clearing duplication of tars received.
- Audit pre/post-adjudicated dental claims for accuracy per documented procedures and regulations.
- Analyzed payments, procedures, and guidelines for benefits.
- Adjusted procedure codes as the need to match the procedure that was done.
- Processed x-rays for accuracy for treatment billed.
- Maintain a daily average number of processed claims.
Customer Service Representative
Delta Dental of California
10.2017 - 01.2019
- Relay proper insurance information in a timely fashion.
- Responded to customer requests for products, services, and company information.
- Provided primary customer support to internal and external customers.
- Give a proper explanation of claim processing information to providers and members.
- Complete member grievance.
- Take requests for I'd cards, material requests, and call-back requests.
- Answered customer telephone calls promptly to avoid on-hold wait times.
- Maintained customer satisfaction with forward-thinking strategies focused on addressing customer needs and resolving concerns.
Office Supervisor/Scheduler/Treatment Plan Coordinator
Dr. Terri Speed
08.2004 - 10.2017
- Bills proper insurance companies for dental work and pre-determination.
- Knowledge of HMO, PPO dental plans, and knowledge of dental CDT codes.
- Schedules appointments, orders office supplies, answer phones, prepares new patient charts, and files charts alphabetically.
- Verifies patient's insurance coverage PPO/ HMO.
- Acts as the treatment plan coordinator.
- Complete patient registration packets and collect patient co-pays.
- Maintained employees' shifts and hours.
- Processed payroll through ADP accounting.
- Developed comprehensive work manuals.
- Creating training classes for new employees.
Registered Dental Assistant
Dr. Terri Speed
08.2004 - 10.2017
- Directs patient care, and routine laboratory functions.
- Certified in CPR and X-ray licensed.
- Sound knowledge of clinical procedures and dental/ medical terminology.
- Builds and maintains a positive working relationship with co-workers.
- Maintains the record of lab cases.
- Makes temp, crowns & bridges, and assists with dental procedures.
- Updates patient's medical history records existing restorations on new and existing patients.
- Sterilizes instruments and sets up procedure trays.
Education
MBA - Business Administration
Southern New Hampshire University
Hooksett, NH07-2024
Bachelor of Arts - Business Administration
Southern New Hampshire University
Hooksett, NH04-2023
Bachelor of Arts - Business Administration
Southern New Hampshire University
Hooksett, NH12-2022
Skills
- Claims analysis
- Data privacy initiatives
- Claims analysis
- Dispute tracking
Timeline
Professional Claims Analyst
Gainwell Technologies
05.2024 - Current
Quality Management Auditor
Delta Dental of California
06.2022 - 05.2024
Dental Auditor
Delta Dental of California
01.2019 - 06.2022
Customer Service Representative
Delta Dental of California
10.2017 - 01.2019
Office Supervisor/Scheduler/Treatment Plan Coordinator
Dr. Terri Speed
08.2004 - 10.2017
Registered Dental Assistant
Dr. Terri Speed
08.2004 - 10.2017
MBA - Business Administration
Southern New Hampshire University
Bachelor of Arts - Business Administration
Southern New Hampshire University
Bachelor of Arts - Business Administration
Southern New Hampshire University
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