Susan L. Walley
Jefferson,GA
Summary
Diligent Claims Examiner with solid background in processing and evaluating insurance claims. Effectively managed numerous cases, ensuring accurate and timely resolution. Demonstrated strong analytical skills and attention to detail in complex claim assessments.
Overview
21
21
years of professional experience
Work History
Claims Examiner
Cognizant Technology Solutions, CTS
211 Quality Circle, Station, TX77845
02.2019 - Current
- Evaluated and processed insurance claims with accuracy and attention to detail.
- Analyzed claim data to identify trends, discrepancies, and potential fraud risks.
- Collaborated with internal departments to resolve complex claims issues efficiently.
- Mentored junior examiners on best practices in claims processing and adjudication.
- Ensured compliance with regulatory standards throughout the claims examination process.
Claims Processor
Next Level Business Services, Inc,.7470 141st St. 151
Seminole, FL 33776
01.2017 - 02.2019
- Processed claims with high accuracy, ensuring compliance with healthcare regulations and guidelines.
- Reviewed documentation to verify eligibility and determine claim status, minimizing errors in processing.
- Collaborated with cross-functional teams to resolve complex claims issues, enhancing overall workflow efficiency.
- Trained new processors on claim handling procedures and system navigation, fostering a knowledgeable team environment.
- Processed medical claims efficiently, ensuring adherence to regulatory guidelines and payer requirements.
- Reviewed and verified claim accuracy, resolving discrepancies with providers and patients promptly.
- Utilized electronic claims processing systems to streamline workflow and enhance data integrity.
- Coordinated communication between clients and insurance providers for claim resolution.
Dell Services (NTT Data Services)
HC & Insurance OPS Associate
Oklahoma City, OK
05.2016 - 01.2017
- Assignment with DST Health Solutions May 2016–January 2017
- Self-motivated, with a strong sense of personal responsibility.
- Worked effectively in fast-paced environments.
- Skilled at working independently and collaboratively in a team environment.
- Proven ability to learn quickly and adapt to new situations.
- Analyzing and updating information for both medical and hospital submissions in a pended status. Navigating the Amisys screens; ascertain the billing provider's affiliation, applying defined policies for documentation, and determining medical necessity for anesthesia allowance, examining the workflow before claims for processing and applying the proper resolution.
- Figuring anesthesia allowance, adhering to the company billed claims procedures.
- Retrieval of prior claim remittance and completing the proper workflow for claims.
- Continuing to refine skills and remain versatile in a multitude of taskwork responsibilities.
- Achieving the company's required goals on Compliance scores.
Claims Processor
BroadPath Healthcare Solutions
Tucson, AZ
10.2014 - 12.2015
- Assignment with Valence Health, DBA Kentucky Health Cooperative, December 2015.
- Assignment with Valence Health, DBA Valence Health, December 2015.
- Responsibilities were reviewing governmental claims for completeness and accuracy.
- Research the missing information by viewing the Aldera system database.
- Finalizing the claim for payment or denial and documenting the status.
Claims Examiner II
Excellus Blue Cross/Blue Shield
Rochester, NY
02.2005 - 10.2014
- Efficiently resolve wide variety of complex claims transactions in telecommuting environment.Efficiently resolve wide variety of complex claims (inpatient and outpatient) submissions.Code Medicaid claims from hospitals (inpatient and outpatient) involving research, data entry of charges, ICD10, and CPT4 coding procedures.Complete Customer Service and Provider Audit Inquiries involving research, data entry of charges, ICD10, and CPT4 coding procedures.Complete Customer Service and Provider Audit Inquiries involving research, data entry of charges, ICD10, and CPT4 coding procedures.Processed claims, documentation of changes, explanation of benefits, and adjustment to claims to assure proper payment.Efficiently resolve wide variety of complex claims (inpatient and outpatient) submissions.Code Medicaid claims from hospitals (inpatient and outpatient) involving research, data entry of charges, ICD10, and CPT4 coding procedures.Complete Customer Service and Provider Audit Inquiries involving research, data entry of charges, ICD10, and CPT4 coding procedures.Complete Customer Service and Provider Audit Inquiries involving research, data entry of charges, ICD10, and CPT4 coding procedures.Processed claims, documentation of changes, explanation of benefits, and adjustment to claims to assure proper payment.Researched claims and incident information to deliver solutions and resolve problems.Efficiently resolve wide variety of complex claims (inpatient and outpatient) submissions.Code Medicaid claims from hospitals (inpatient and outpatient) involving research, data entry of charges, ICD10, and CPT4 coding procedures.Complete Customer Service and Provider Audit Inquiries involving research, data entry of charges, ICD10, and CPT4 coding procedures.Complete Customer Service and Provider Audit Inquiries involving research, data entry of charges, ICD10, and CPT4 coding procedures.Processed claims, documentation of changes, explanation of benefits, and adjustment to claims to assure proper payment.Finalized files for insurance claim payment release.Handled sensitive information with discretion, ensuring confidentiality of personal and financial details for claimants throughout the claims examination process.Enhanced customer satisfaction by promptly addressing inquiries and providing accurate information on claim status.
- Efficiently resolve wide variety of complex claims (inpatient and outpatient) submissions.
- Code Medicaid claims from hospitals (inpatient and outpatient) involving research, data entry of charges, ICD10, and CPT4 coding procedures.
- Complete Customer Service and Provider Audit Inquiries involving research, data entry of charges, ICD10, and CPT4 coding procedures.
- Complete Customer Service and Provider Audit Inquiries involving research, data entry of charges, ICD10, and CPT4 coding procedures.
- Processed claims, documentation of changes, explanation of benefits, and adjustment to claims to assure proper payment.
- Finalized files for insurance claim payment release.
- Handled sensitive information with discretion, ensuring confidentiality of personal and financial details for claimants throughout the claims .vexamination process.
- Enhanced customer satisfaction by promptly addressing inquiries and providing accurate information on claim status.
Education
Associate of Applied Science - Medical Assistant
Bryant & Stratton
Rochester, NY06-1981
Skills
- Extensive experience in insurance claims processing
- Understanding of medical terminology, ICD9, ICD10, and CPT coding
- Knowledge of Medicare UB04, CMS1500
- Outstanding customer service and problem solving skills with a high level of production and accuracy
- Superior work ethic, self-motivated, and able to work well independently in a telecommuting position
- Excellent organizational skills, efficiently prioritizing tasks while working in a fast-paced environment
- Experience with QNXT, Medisca, Managed Care and Commercial
- Experienced with Microsoft Office applications
- Proficiently use Facets, Amisys, and Aldera systems to complete daily tasks
- Claims processing
- Verbal communication
- Data verification
- Disability claims process
- AMS360
Accomplishments
Completed a Prompt Engineering course 9/2025
Member of Eastern Star
While living in NY was part of this organization. There were volunteer opportunities to help the community.
Timeline
Claims Examiner
Cognizant Technology Solutions, CTS
02.2019 - Current
Claims Processor
Next Level Business Services, Inc,.7470 141st St. 151
01.2017 - 02.2019
Dell Services (NTT Data Services)
HC & Insurance OPS Associate
05.2016 - 01.2017
Claims Processor
BroadPath Healthcare Solutions
10.2014 - 12.2015
Claims Examiner II
Excellus Blue Cross/Blue Shield
02.2005 - 10.2014
Associate of Applied Science - Medical Assistant
Bryant & Stratton