Rosalyn Augustine

Analyzed and investigated hospital medical cases for accurate claims processing.

Assisted in processing medical and hospital claims, including Scripts and J codes.

Reprocessed Orthonet claims to ensure compliance with regulations.

• Supported various projects as needed to enhance operational efficiency.

Analyzed facility and professional claims to ensure alignment with provider contracts and benefits provisions.

Executed system edits and initiated correspondence to notify providers and members of claims decisions.

Processed medical claims from QcareWE system to support cost containment initiatives.

Met productivity, quality, and cycle time performance metrics consistently.

Assessed patient and medical information to determine necessity for investigation into Coordination of Benefits and other programs.

Utilized procedure codes (CPT), diagnosis codes (ICD-9), and POS/TOS codes to make precise claims decisions.

Maintained comprehensive knowledge of claims processing systems to evaluate accuracy and recommend enhancements.

Entered preauthorization and referrals for various claims types within Utilization department.