Princess Crockett
Chicago,IL
Summary
Possesses versatile skills in medical insurance claims processing and auditing. Experienced with analyzing and verifying claims for compliance and payment accuracy. Utilizes strong analytical skills to identify and resolve discrepancies efficiently with a thorough understanding of claims processing. Willingness to learn, and reliable team player with strong commitment to adaptability and accuracy.
Overview
12
12
years of professional experience
Work History
Claims Auditor
Group1001 Resources, LLC
12.2019 - 12.2025
- Processed electronic institutional and professional Medicare claims according to Medicare and departmental policies and procedures.
- Processed 150-250 claims per day for three lines of businesses in the Invidasys claim system.
- Investigated, evaluated and determined accuracy of payment according to procedure.
- Audited claims with regulatory standards and internal policies.
- Identified inconsistencies or discrepancies in claims and report them to the appropriate departments.
- Worked closely with junior claims processors and management to resolve claim issues.
- Assisted in training employees on new procedures or policies to ensure accurate claim processing.
- Prepared reports detailing audit findings and recommendation.
- Researched and adjusted overpayment, underpayment, and deny unjustified claims.
- Audited and identified provider negative balances, and aided in debt recovery.
- Worked with the finance department to process claim payment runs on a weekly basis. Reissue void payments on a monthly basis and reissue payments to providers for uncleared checks when requested.
- Assisted claims management with CMS audits.
- Coordinated with internal departments and TPA (Claims, Credentialing, Operation, Enrollment, Utilization Management, etc.) to research and resolve provider issues.
- Monitored and triaged incoming communications and email inquiries from providers.
- Prioritized, and routed provider requests to the appropriate internal team for timely resolution.
Claims Specialist
Family Health Network/Community Care Alliance of Illinois
11.2016 - 12.2019
- Processed electronic institutional and professional Medicaid and Medicare claims according to departmental policies and procedures.
- Manually processed Medicare claims using Medicare pricer tool when necessary.
- Processed 150-300 claims per day in the Invidasys claim system.
- Investigated, evaluated and determined accuracy of payment according to procedure.
- Researched and adjusted overpayment, underpayment, and deny unjustified claims.
- Reviewed and processed COB claims.
- Resolved claims issues received from member and provider services department in a timely manner.
- Worked various claims projects.
- Reviewed and assessed claim submissions for accuracy, identifying discrepancies and initiating corrections.
Claims Supervisor
Chicagoland Medical Services Organization
01.2014 - 02.2016
- Trained internal and external claim specialist and mentored staff on best practices for claims management and dispute resolution.
- Assisted management with hiring and termination process.
- Supervised claims processing team, ensuring adherence to policies and regulatory requirements under Medicaid and Medicare.
- Enhanced team productivity by providing ongoing training and mentorship to claims adjusters.
- Managed and distributed projects and other tasks.
- Processed Medicare, Medicaid claims, and assisted with processing Humana claims.
- Processed 250-350 claims per day in the QuickCap claim system.
- Audited claims, processed check runs, EFT payments, issued checks, and Explanation of benefits and Explanation of payments
- Imported EDI files into the claim system.
- Verified eligibility, PCP status and benefits.
- Ensured the accuracy of provider files entered and updated in the claim system.
Education
Billing & Coding
Computer Systems Institute
Chicago, Illinois11.2013
Skills
- Insurance claims processing
- Claims auditing
- Claims investigation
- ICD-9/10CM
- Medical insurance/EOB and EOP
- Ability to supervise and train others
- Team collaboration
- Detailed-Oriented
- Workload prioritization
- Reliability
Timeline
Claims Auditor
Group1001 Resources, LLC
12.2019 - 12.2025
Claims Specialist
Family Health Network/Community Care Alliance of Illinois
11.2016 - 12.2019
Claims Supervisor
Chicagoland Medical Services Organization
01.2014 - 02.2016
Billing & Coding
Computer Systems Institute