Work Preference
Summary
Overview
Work History
Education
Skills
Accomplishments
Languages
Work Availability
Timeline
Generic
Open To Work

Sophia Stewart

Work Preference

Job Search Status

Open to work
Desired start date: Immediately

Desired Job Title

Senior Medical Claims ExaminerPatient Care Coordinator for Claims & Benefits Investigation

Work Type

Full Time

Location Preference

RemoteHybridOn-Site
Location: US
Open to relocation: Yes

Salary Range

$45000/yr - $200000/yr

Important To Me

Work from home optionHealthcare benefitsPaid time offPaid sick leave401k match

Summary

Experienced Healthcare Professional with over five years of expertise in Prior Authorization, Medical Claims Processing, and Customer Service. Skilled in handling high-volume inbound and outbound calls, verifying insurance coverage, and working with commercial, Medicare, and Medicaid payers. Proficient in CRM systems, Epic, and McKesson, Salespoint with strong knowledge of ICD-9/10 coding and CPT. Resolving claim issues, ensuring timely authorizations, and maintaining accurate documentation to support healthcare reimbursement processes. Tracked and analyzed payer payment processes, including prior authorization status, and followed up on outstanding claims and denials through regular calls. Utilized Microsoft Excel to track authorization status, maintain detailed records, and generate weekly reports for management. Initiated and completed claim investigations when indicated, including prior authorizations, pre-existing conditions, accidents, medical necessity and appropriateness, eligibility, and coordination of benefits. Reviewed incoming claims and related documentation, verifying prior authorization and ensuring accuracy and completeness.

Overview

9
9
years of professional experience

Work History

Senior Medical Claims Examiner

NTT Data Healthcare Services (Centene Corp.)
08.2018 - 08.2025
  • Reviewed and adjudicated medical claims based on health policy provisions and established guidelines.
  • Requested additional information from members and providers as needed.
  • Processed prior authorization requests by accurately reviewing ICD-9/10 and CPT codes, ensuring compliance with payer guidelines and timely approvals.
  • Verified patient insurance coverage and benefits, communicating findings to patients and providers via inbound and outbound calls.
  • Utilized Microsoft Excel to track authorization status, maintain detailed records, and generate weekly reports for management.
  • Facilitated patient access to medications by collaborating with healthcare providers, insurers, and pharmacies.
  • Investigated and confirmed insurance coverage, patient benefits, and prior authorizations, updating all findings in CRM and Excel.
  • Tracked and analyzed payer payment processes, including prior authorization status, and followed up on outstanding claims and denials through regular calls.
  • Managed enrolment for health, dental, vision, and 401(k) benefits for employees of various companies.
  • Reviewed company policies to determine coverage and assess validity of claim.
  • Initiated and completed claim investigations when indicated, including prior authorizations, pre-existing conditions, accidents, medical necessity and appropriateness, eligibility, and coordination of benefits.
  • Reviewed incoming claims and related documentation, verifying prior authorization and ensuring accuracy and completeness.
  • Addressed inquiries or concerns from drivers related to claim status, payment, and discrepancies. Entered claim information and relevant details into the claims processing system.
  • Applied established guidelines and policies to determine claim eligibility and process claims accordingly.
  • Reported suspected fraudulent claims to the Fraud, Waste, and Abuse (FWA) department.
  • Organized and maintained departmental deadlines, policies, and procedures.
  • Collaborated with other departments to resolve inquiries and concerns.
  • Participate in other projects or duties as assigned.
  • Facilitated communication between insurance providers and patients, clarifying coverage details and addressing concerns.
  • Collaborated with healthcare providers to ensure accurate billing information, minimizing discrepancies and errors.
  • Maintained thorough knowledge of medical terminology and coding systems, contributing to precise evaluations of claim submissions.
  • Worked closely with fraud investigation teams to identify suspicious patterns in submitted claims.
  • Improved claim processing efficiency by implementing new medical claims examination practices and procedures.
  • Continuously sought opportunities for professional development, attending industry conferences and participating in relevant training programs.
  • Mitigated risk exposure by adhering to all policies and regulations governing the medical claims examination process.
  • Managed a high volume of complex cases, ensuring timely resolutions while maintaining attention to detail.
  • Identified areas for cost reduction through meticulous claims analysis and negotiation with providers.
  • Stayed up-to-date on industry trends to inform decision-making processes and anticipate potential challenges.
  • Championed initiatives to incorporate digital tools into the claims examination process for improved efficiency.
  • Streamlined workflow for faster claims resolution, resulting in increased customer satisfaction.
  • Implemented quality control measures to maintain high accuracy levels in the claims examination process.
  • Expertly navigated disputes between parties involved in the claiming process, leading to fair resolutions.
  • Reduced claim denial rates by thoroughly reviewing and validating medical documentation before submission.
  • Consistently met or exceeded performance targets related to claim turnaround times, accuracy rates, and customer satisfaction metrics.
  • Developed strong relationships with healthcare professionals, fostering trust and cooperation for smoother claims processing.
  • Maintained knowledge of benefits claim processing, claims principles, medical terminology, and procedures and HIPAA regulations.
  • Researched and resolved complex medical claims issues to support timely processing.
  • Monitored and updated claims status in claims processing system.
  • Paid or denied medical claims based upon established claims processing criteria.
  • Managed large volume of medical claims on daily basis.
  • Evaluated medical claims for accuracy and completeness and researched missing data.
  • Generated reports on medical claims processing activities and results.
  • Assessed medical claims for compliance with regulations and corrected discrepancies.
  • Reviewed provider coding information to report services and verify correctness.
  • Used administrative guidelines as resource or to answer questions when processing medical claims.
  • Responded to correspondence from insurance companies.
  • Followed up on denied claims to verify timely patient payment and resolution.
  • Identified and resolved discrepancies between patient information and claims data.
  • Processed insurance payments and maintained accurate documentation of payments.
  • Examined claims forms and other records to determine insurance coverage.
  • Delivered exceptional customer service to policyholders by communicating important information and patiently listening to issues.
  • Identified insurance coverage limitations with thorough examinations of claims documentation and related records.
  • Read over insurance policies to ascertain levels of coverage and determine whether claims would receive approvals or denials.
  • Researched claims and incident information to deliver solutions and resolve problems.
  • Analyzed information gathered by investigation and reported findings and recommendations.

Patient Care Coordinator for Claims & Benefits Investigation

CVS Caremark Healthcare (Specialty Pharmacy)
01.2017 - 01.2018
  • Demonstrated excellent data management and data quality skills.
  • Answered questions related to reimbursement benefits, while maintaining productivity with UB04 and HCFA 1500 claim content, and conducted research of varying federal and state Medicaid regulations to determine hospital, ambulatory surgery, and physician provider reimbursement rules.
  • Conduct in-depth benefit investigations to determine patient eligibility and coverage for prescribed medications.
  • Streamline verification processes and prior authorizations, reducing turnaround times and improving efficiency.
  • Maintained organized records in Microsoft Excel, producing reports on authorization status and payer performance.
  • Handled daily inbound and outbound calls to process prior authorizations, accurately applying ICD-9/10 and CPT codes.
  • Used CRM system to document patient interactions, track benefit verification status, and ensure timely follow-up on claims and benefits inquiries.
  • Verified insurance coverage and benefits for patients, providing clear explanations and support during calls.
  • Utilized Microsoft Excel to maintain real-time logs of authorization requests, approvals, and denials.
  • Verified insurance for limits and parameters of policy.
  • Resolved adjudication issues for paper claims and direct member reimbursements.
  • Determined if prior authorization of precept is necessary.
  • Processed or reversed online claims as required according to edits.
  • SOFTWARE: EPIC, CMP (Claims Management Program), EZCAP, QNXT, Xcelys, Web Strat, Optum Pricer.

Education

Bachelor's degree - business administration

Nova Southeastern University-Davie
Davie, FL
05.2021

Master of Science - Business Administration And Management

Nova Southeastern University
Davie, FL
05-2021

Skills

  • Proficient in Epic and McKesson for Medicare claims processing
  • Claims reimbursement processing
  • Authorization management
  • Information collection and analysis
  • Commercial expertise
  • Visual and verbal problem-solving
  • Medicare knowledge
  • Strong verbal communication
  • Researching Medicaid and Medicare regulations
  • Medicaid compliance expertise
  • Five years in healthcare revenue cycle management
  • Data standardization and validation
  • Data management expertise
  • Proficient in Microsoft Word
  • Advanced Excel proficiency
  • Business analysis
  • Database management with MySQL
  • Requirements analysis
  • Database querying

Accomplishments

  • Documented and resolved escalated which led to one stop shop resolution.
  • Achieved 100% satisfactory customer experience by completing full scope of issue with accuracy and efficiency.
  • Used Microsoft Excel to develop inventory tracking spreadsheets.

Languages

English
Native or Bilingual

Work Availability

monday
tuesday
wednesday
thursday
friday
saturday
sunday
morning
afternoon
evening
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Timeline

Senior Medical Claims Examiner

NTT Data Healthcare Services (Centene Corp.)
08.2018 - 08.2025

Patient Care Coordinator for Claims & Benefits Investigation

CVS Caremark Healthcare (Specialty Pharmacy)
01.2017 - 01.2018

Bachelor's degree - business administration

Nova Southeastern University-Davie

Master of Science - Business Administration And Management

Nova Southeastern University

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