Sarah Brooks
Lutz,FL
Summary
Applied comprehensive understanding of coding terminology and insurance regulations to support healthcare operations and improve service delivery.
Overview
15
15
years of professional experience
Work History
Senior SCA Claims Business Process Analyst
Optum Serve
04.2023 - Current
- Facilitated claims support through comprehensive review, research, investigation, and auditing processes.
- Experience with running reports in SQL Server and compiling reports for upper leadership.
- Utilize Service Now program in collaboration with other departments.
- Work on end-to-end resolution of VA CCN provider abrasion issues.
- Perform check functions 25%-30% of the time including outbound and inbound calls to and from providers.
- Solving moderately complex problems, conducting data analysis.
- Attends/Hosts provider calls to assist with resolving provider claim issues.
- Work with PGBA to resolve and implement system fixes to prevent future provider abrasion.
- Work cross functionally with other departments such as VA, Network OPS and Finance.
- Claims Audit Analyst – 9/2021-1/2023
- Reviewed medical claims on risk contracts for payment accuracy and recovery.
- Identified and quantified issues, as well as recommended new audit criteria.
- Prepared detailed analyses on payment abnormalities and/or questionable payment practices.
- Recorded all claims contested into the contesting database and updated monthly, as required.
- Maintained productivity expectations
- Collaborated with Physicians, Case Managers, Provider Contracting, and Medical Management
- Obtained and reviewed all necessary medical record and billing information data from centers, hospitals, nursing homes, etc. in line with HIPAA requirements.
- Assisted with the identification of process improvement opportunities based on claims audit review.
- Participated in conference calls with managers / directors to provide findings, as required.
Medical Call and Claims Auditor
People Premier
04.2021 - 09.2021
- Audited adjudicated medical insurance claims and customer service calls to ensure validity, accuracy, and compliance with appropriate policies, procedures, and regulations.
- Completed 25-30 Call audits per day which met department standards.
- Prepared written audit reports based on findings and communicated audit findings with appropriate leadership.
- Identified patterns, trends, and variances related to claims and calls and provided feedback to Member Services.
Grievance & Appeals Representative I
Centene Corporation (formerly WellCare)
06.2019 - 04.2021
- Responsible for completing 15-17 FL Medicaid appeals files per day. I have consistently met and even exceeded this goal each monthly review.
- Frequently exceeded quality metric of 95% accuracy.
- Logged, tracked and processed health service appeals.
- I interacted with other departments including Customer Service, Claims, and Pharmacy to resolve provider appeals.
- Made administrative appeal determinations when indicated and properly set up case files for clinical review when needed.
- Conducted general appeal research and filing including, but not limited to, requesting waivers of liability and/or appointment of representative forms, organizational determination research, requesting member medical records, organizing documentation, preparing written summaries, scheduling the case, processing the review of case, documentation of the appeal resolution and sending completed case files to external review organizations as required by regulatory guidelines.
- Maintained all documentation associated with the processing and handling of appeals to comply with regulatory standards and timeframes while maintaining an accurate, complete appeals record in the electronic database.
- Notified Supervisor or other appropriate parties of identified patterns of appeals, claim errors, configuration issues, or other systemic problems identified during appeal processing.
Senior Claims Adjustor
Aetna, Inc.
09.2018 - 06.2019
- Reviewed and adjudicated complex, sensitive, and/or specialized claims adjustments in accordance with processing guidelines.
- Acted as a subject matter expert by providing training, coaching, or responding to complex issues.
- Reviewed pre-specified claims or claims that exceeded specialist adjudication authority or processing expertise.
- Ensured all compliance requirements were satisfied and that all payments were made against company practices and procedures.
- Identified and reported possible claim overpayments, underpayments, and any other irregularities.
Healthcare Claims Auditor
NTT Data Corporation
Plano, TX
12.2017 - 07.2018
- Responsible for documenting detailed results in an audit database for tracking and reporting.
- Responsible for training and measurement against predetermined Quality and Productivity standards within the department as well as deadlines for completion of all audits.
- Ability to comprehend and follow benefit and/or provider contract language and various policies and rules.
- Responsible for identifying errors, conducting a preliminary root cause analysis, determining quality issues, and corrective action’s needs.
- Communicated findings and validated corrections were made.
- Attended meetings and participated in projects, as were needed.
- Improved efficiency, and quality in processes, turnaround and/or procedures.
Claims Examiner
UnitedHealthcare
01.2016 - 03.2017
- Processed UB-04 and CMS-1500 claim forms accurately.
- Entered claims into computer systems utilizing CPT and ICD-9 knowledge.
- Verified accuracy of information on all received medical claims.
- Identified and reported overpayments, underpayments, and discrepancies.
- Utilized multiple computer systems to capture data effectively.
- Updated claim details based on member and provider communications.
- Adjusted claims to apply appropriate benefits.
Provider Claims Resolution Specialist
UnitedHealth Group
06.2011 - 05.2014
- Performed all types of complex adjustments and closed, denied, and simple adjustments.
- Met quality, productivity, and attendance requirements.
- Responsible for follow-up work needed for resolving and closing issues.
- Identified and resolved anticipated Provider issues to prevent future calls.
- Complied with all policies, procedures, and workflows.
- Researched claim inquiries and benefit/eligibility information.
- Followed HIPAA regulations and gained familiarity with Medicare guidelines.
Education
Bachelor of Science - Criminology
University of Tampa
Tampa, FL12.2005
High School Diploma -
Tampa Catholic High School
Tampa, FL05.2002
Skills
Over 11 years of experience in medical claims processing
Assisted in generating high-complexity reports using SQL Server
Applied UB-04 and CMS-1500 coding with proficiency in CPT and ICD-9/10 medical terminology
Processed claims and reviewed explanation of benefits (EOBs)
Utilized Microsoft Office tools including Word, Excel, and Outlook with typing speed of 85 WPM
Timeline
Senior SCA Claims Business Process Analyst
Optum Serve
04.2023 - Current
Medical Call and Claims Auditor
People Premier
04.2021 - 09.2021
Grievance & Appeals Representative I
Centene Corporation (formerly WellCare)
06.2019 - 04.2021
Senior Claims Adjustor
Aetna, Inc.
09.2018 - 06.2019
Healthcare Claims Auditor
NTT Data Corporation
12.2017 - 07.2018
Claims Examiner
UnitedHealthcare
01.2016 - 03.2017
Provider Claims Resolution Specialist
UnitedHealth Group
06.2011 - 05.2014
Bachelor of Science - Criminology
University of Tampa
High School Diploma -
Tampa Catholic High School