Sandra McGee
Carson,CA
Summary
Experienced and accomplished Claims Specialist 2 with over five years of experience processing claims looking to utilize extensive background in customer service and claims processes into a Senior Claims Examiner position.
Overview
13
13
years of professional experience
Work History
Claims Specialist 2
Optum
El Segundo, CA
10.2018 - Current
- Verifies and interprets information in vendor contracts to resolve claim issues
- Troubleshoots claims that require an authorization
- Processes UB04 claims and performs claims adjustments as needed
- Reviewed and analyzed insurance claims to determine validity, completeness, accuracy, and eligibility for payment.
- Investigated complex or high-value claims to identify discrepancies and fraud indicators.
- Processed payments for valid claims according to established procedures.
- Interpreted legal documents related to claims processing such as contracts and policy language.
- Identified trends in rejected claims that could indicate system errors or fraudulent activity.
- Resolved claims by approving or denying documentation, calculating benefits due and determining compensation settlement.
- Tracks progress of resolution of claims issues and reroutes resolved claims
- Uses, protects, discloses patient’s protected health information only in accordance with HIPAA standards.
Customer Service Representative
HealthCare Partners Medical Group
Torrance, California
10.2010 - 09.2018
- Provide quality assurance for customer’s individual requests
- Answered customer inquiries and provided accurate information regarding claims.
- Resolved complex problems by working with other departments to provide solutions that meet customer needs.
- Provided excellent customer service to resolve customer issues in a timely manner.
- Maintained detailed records of customer interactions, transactions and comments for future reference.
Education
Certified Phlebotomist -
Southern California Regional Occupational Center
05.2010
Certified Medical Assistant -
Southern California Regional Occupational Center
02.2010
Skills
- Eligibility Determination
- Claim Amount Calculations
- New Policies Processing
- Policy Modifications and Updates
- Teamwork and Collaboration
- Attention to Detail
- Critical Thinking
- Data Integrity
- Understanding of Medical Terms
- Claims Processing
- Medical Terminology
Timeline
Claims Specialist 2
Optum
10.2018 - Current
Customer Service Representative
HealthCare Partners Medical Group
10.2010 - 09.2018
Certified Phlebotomist -
Southern California Regional Occupational Center
Certified Medical Assistant -
Southern California Regional Occupational Center
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