Tara Dale-Gaye
Humble,Texas
Summary
Detail-oriented Claims Audit Processing Professional with extensive experience in Managed Care. Expertise in reviewing, analyzing, and auditing insurance claims for compliance and accuracy. Proficient in identifying discrepancies and resolving issues to meet regulatory standards. Committed to optimizing claim processing workflows to enhance efficiency and reduce errors.
Overview
19
19
years of professional experience
Work History
Independent Contractor
Self-employeed
07.2024 - Current
- Created and managed project plans, timelines and budgets.
- Developed and maintained strong working relationships with clients, leading to repeat business and referrals.
- Delivered outstanding service to customers to maintain and extend relationships for future business opportunities.
Claims Audit Analyst/Senior Claims Examiner
HCHD (Community Health Choice)
04.2010 - 01.2024
- Resolved payment discrepancies and appeals by identifying root causes effectively.
- Reviewed policies, contracts, and guidelines to ensure claim accuracy and compliance.
- Processed Medicaid Star, Chip, and P claims using the QNXT system efficiently.
- Maintained market standards and service levels, ensuring high customer satisfaction.
- Developed training materials and assisted in training claims team on refunds.
- Achieved department goals by managing aging timeframes and quality standards.
Technical Claims Specialist
Coventry Health Care
12.2006 - 04.2010
- Ensured compliance with Medicare by accurately adjudicating medical claims.
- Resolved payment discrepancies and appeals through thorough research and adjustments.
- Achieved departmental goals for productivity, aging timeframe, and quality standards.
- Mentored new employees and provided training updates for existing staff members.
- Addressed provider and member inquiries regarding claims and benefits issues.
- Maintained high coding accuracy and productivity using ICD-9, ICD-10, HCPCS, and CPT.
Education
High School Diploma -
Mt Diablo High School
Concord, CASkills
- MS Word, Excel, PowerPoint
- MS Outlook, Teams
- QNXT
- JIVA
- NetworXPricer
- Deadline adherence
- Project management
- Scheduling
- Schedule management
- Error correction
- Performance metrics
- Cross-functional coordination
- Time management
- Attention to detail
- Customer support
- Problem-solving
- Critical thinking
- Data analysis
- Multitasking and organization
- Change Health Care Systems
- 10 Key Skills, Typing 55wpm
- Medical coding, CPT, ICD10, HCPS Knowledge
- Writing/Composing (Correspondence / Reports)
- Coordination of Benefits
- Client relationship building
- Workload management
Timeline
Independent Contractor
Self-employeed
07.2024 - Current
Claims Audit Analyst/Senior Claims Examiner
HCHD (Community Health Choice)
04.2010 - 01.2024
Technical Claims Specialist
Coventry Health Care
12.2006 - 04.2010
High School Diploma -
Mt Diablo High School