THECLA B. RIVERS
New Orleans
Summary
Talented Team Lead experienced and dedicated to enhancing employee satisfaction and business success. Proven success in managing teams and adapting to dynamic work environments. Known for reliability, flexibility, and strong organizational skills, ensuring seamless team operations and achievement of goals. Diplomatic and friendly with proven commitment to employee training. Hardworking team player bringing necessary experience and knowledge to tackle any operational demand.
Overview
17
17
years of professional experience
Work History
Team Lead - Ancillary Claims
Pan-American Life Insurance
01.2022 - Current
- Conducts claims review using claims processing guidelines.
- Identifies and communicates processing discrepancies or trends.
- Validates claim outcomes for accuracy and route for payment or adjustment.
- Approve claims up to authority limit meeting department processing standards.
- Provide guidance and training on processing claims.
- Support team members with technical expertise on completion of tasks.
- Coordinates with Claims Teams, Account Managers, Accounting Teams and Customer Service to complete tasks and claim payments when extra information is needed.
Team Lead - Medical Claims
Pan-American Life Insurance
11.2018 - 01.2022
- Evaluates and provide appropriate documentation for team member reviews
- Develop and coordinate educational and training programs regarding elements of correct payment of claims
- Implement corrective action plan and/or educational programs to prevent denials and rejection of claims
- Meet with other Team Leads, Supervisor and Manager to review findings of employee performance and recommend ways to improve performance when indicated
- Trained new team members by relaying information on company procedures and safety requirements.
- Promoted a positive work environment by fostering teamwork, open communication, and employee recognition initiatives.
Claims Auditor
Pan-American Life Insurance
11.2016 - 10.2018
- Audits diagnosis codes and professional fee services submitted on claims for payment according to ICD10, CPT, HCPCS, and CMS guidelines
- Responsible for maintaining up to date knowledge of coding guidelines as they relate to billing and claims payment
- Report trends found during claim review process to implement corrective action and/or educational opportunities for team members
- Meet with Team Leads, Supervisor and Manager to review findings of employee performance and recommend ways to improve performance when indicated
Business Associate II - Claims Processor
Pan-American Life Insurance
06.2010 - 11.2016
- Enter claims data, adjudicate claims and code explanation of benefits
- Investigate provider and claimant inquiries on claim payments and denials
- Request refunds on overpayment of claims
Business Associate I - Claims Processor
Pan-American Life Insurance
06.2008 - 06.2010
- Enter claims data, adjudicate claims and code explanation of benefits
- Investigate provider and claimant inquiries on claim payments and denials
- Request refunds on overpayment of claims
Education
Associate of Science - Health Information Tech
Delgado Community College
New Orleans, LA05.2000
Skills
- Claims Processing
- Research and data analysis
- Ability to identify, analyze and solve problems
- Attention to detail
- Ability to meet or exceed performance competencies
- Customer focus
- Coaching and mentoring
- Excellent verbal and written communication skills
- Ability to work independently and within a team environment
- Computer proficiency and technical aptitude with the ability to utilize MS Office including Excel spreadsheets
Work Preference
Work Type
Full TimeWork Location
RemoteImportant To Me
Flexible work hoursCompany CultureWork-life balancePersonal development programsHealthcare benefitsCareer advancementWork from home optionPaid time offTeam Building / Company RetreatsPaid sick leave401k matchStock Options / Equity / Profit Sharing4-day work weekWork Availability
monday
tuesday
wednesday
thursday
friday
saturday
sunday
morning
afternoon
evening
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Timeline
Team Lead - Ancillary Claims
Pan-American Life Insurance
01.2022 - Current
Team Lead - Medical Claims
Pan-American Life Insurance
11.2018 - 01.2022
Claims Auditor
Pan-American Life Insurance
11.2016 - 10.2018
Business Associate II - Claims Processor
Pan-American Life Insurance
06.2010 - 11.2016
Business Associate I - Claims Processor
Pan-American Life Insurance
06.2008 - 06.2010
Associate of Science - Health Information Tech
Delgado Community College
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