Ryan H.A. Somers
TMF Health Quality Institute
Tampa,Fl
22
years of professional experience
Seeking a position in a company which will require me to utilize my skills, abilities and experience to ensure the company’s success.
Work History
Dispute Resolution Reviewer
4 Months- Reviewed medical records for compliance with CMS guidelines and program requirements.
- Evaluated documentation accuracy to support quality assurance and case determination decisions.
- Interpreted regulatory criteria to ensure consistent review outcomes across assigned cases.
- Analyzed clinical evidence and flagged discrepancies requiring follow-up or clarification.
Appeals Specialist
4 Years 1 Month- Reviewing and triaging denied provider appeals.
- Sending and creating letters to those providers who appeal has been denied or paid using Microsoft Word template informing them of the decision on the appeal.
- Analytically deciding whether the appeal is in compliance based on company standards and policies.
Claim Examiner
4 Years 9 Months- Reviewing and researching insurance claims from inpatient or outpatient medical claims, workers comp, and to auto insurance determine possible payment accuracy.
- Validating Member, Provider and other Claims information.
- Determining accurate payment criteria for clearing pending claims based on defined Policy and Procedure.
- Coordinating Claim Benefits based on the Policy & Procedure.
- Maintaining productivity goals, quality standards and aging timeframes.
- Scrutinizing Medical Claim Documents and settlements.
- Reviewing clinical documents to determine payment or whether an appeal supports the service provided for all lines of services from inpatient or outpatient.
Claim Examiner
1 Year 8 Months- Adjudicating and processing medical claims at home position
- Handling claims authorizations and coordination of benefits as a third party for Aetna.
- Knowledge of repricing claims, contracts, and icd coding and etc.
Medicare/ Medicaid Claim Examiner
1 Year 6 Months- Providing customer service to clients, providers and plan participants.
- Understanding plan benefits in order to provide current and accurate information to a caller and seeking additional information from external sources as needed.
- Reviewing complex or unusual claim including claims previously processed incorrectly and forwarding to designated personnel with recommended corrective actions.
- Issue written correspondence to clients, providers, or plan participants.
- Recording call data in One Note or Anthem Blue Cross system.
- Knowledge of Icd-9 to Icd -10 billing codes, modifiers, and diagnosis as they vary by state, medicare, and Medicaid.
Provider Specialist/Claims
2 Years 5 Months- Handle inbound calls from new and existing Medicare Beneficiaries.
- Knowledgeable of HIPAA rules and CMS policies and regulations.
- Supply web assistance on Medicare Drug, Advantage Plans, and Medigap Policy questions.
- Enroll callers into plans if needed assistance.
- Researching claims information.
Education
Associate Degree
as of
Graduated
Skills
Some IT Experience
Knowledgeable of Medical Appeals
Microsoft Office Suite & Slack
Knowledge of ICD Coding
Excellent project planning
Knowledge of Salesforce and Amysis
55wpm
Timeline
Dispute Resolution Reviewer
TMF Health Quality Institute
06.2026 - CurrentRead More
Appeals Specialist
Emblemhealth
02.2022 - 03.2026Read More
Claim Examiner
NTT Data Services
03.2021 - 12.2025Read More
Claim Examiner
FirstSource Healthplans
07.2019 - 03.2021Read More
Medicare/ Medicaid Claim Examiner
Continental Benefits/ Wellsystems
02.2016 - 08.2017Read More
Provider Specialist/Claims
General Dynamics International Technology
05.2004 - 10.2006Read More
Bloomingdale High School
Read More
Bryant & Stratton University
Associate Degree
Read More