Thomas Spaulding
Ontario,US
Summary
Medical Claims Examiner with 10+ years of experience in claims resolution and compliance with Medicare and Medi-Cal standards. Expertise in healthcare software and electronic records management enhances claims processing efficiency and accuracy. Proven problem-solving abilities and quality control skills drive high customer service standards and deliver measurable results.
Overview
15
15
years of professional experience
Work History
CLAIMS EXAMINER SR
Astrana Health
01.2022 - Current
- Analyze claim disputes, ensuring compliance with Medicare and Medi-Cal guidelines.
- Generate detailed reports, addressing provider feedback to enhance claim accuracy.
- Issue denial letters and refund requests, streamlining claims processing.
- Manage records and documents using Microsoft Office and specialized software.
- Ensure claims processing aligns with health plan contracts, achieving measurable results.
- Streamlined claims processing by analyzing dispute trends, ensuring compliance with Medicare guidelines, and achieving more efficient resolution times.
CLAIMS DISPUTE RESOLUTION SPECIALIST
CalOptima
01.2021 - 01.2022
- Resolved complex claim disputes, adhering to Medicare and Medi-Cal standards.
- Issued precise denial letters, enhancing documentation accuracy.
- Managed records using Microsoft Office and specialized software.
- Analyzed claim data to boost processing efficiency.
- Identified trends in denied claims, reducing rejections with targeted actions.
CLAIMS DISPUTE RESOLUTION SPECIALIST
Imperial Health Plan of California
01.2020 - 12.2021
- Resolved claim disputes, ensuring adherence to Medicare and Medi-Cal guidelines.
- Issued detailed denial letters, efficiently managing refund requests.
- Organized records for improved data accessibility and accuracy.
- Used Microsoft Office and specialized software for precise reporting.
- Evaluated denied claims to identify trends, enhancing resolution times.
CLAIMS EXAMINER 3
North American Medical Management
01.2016 - 01.2020
- Analyzed medical claims for accuracy, resolving issues promptly.
- Negotiated claims, enhancing processing efficiency.
- Maintained electronic records, improving data access.
- Collaborated with providers for comprehensive information.
- Used software tools to streamline claims management.
APPOINTMENT CLERK
Kaiser Permanente Appointment Center
01.2011 - 01.2016
- Efficiently scheduled appointments, improving patient satisfaction and flow.
- Resolved inquiries, enhancing call center efficiency and service quality.
- Processed referrals and updated records, ensuring accuracy and compliance.
- Composed messages for medical staff, boosting communication effectiveness.
- Applied guidelines and laws, maintaining high standards of service.
Education
High School Diploma - GED
Citrus High
Fontana, CASkills
- Medical terminology
- Data entry efficiency
- Healthcare regulations
- Medical coding expertise
- Medical record review
- ICD codes
- Customer service and support
Analytical thinking Medical coding (HCPCS & ICD-10) Medicare regulations Medi-Cal and Medicaid
Websites
LINKS
LinkedIn: www.linkedin.com.
Timeline
CLAIMS EXAMINER SR
Astrana Health
01.2022 - Current
CLAIMS DISPUTE RESOLUTION SPECIALIST
CalOptima
01.2021 - 01.2022
CLAIMS DISPUTE RESOLUTION SPECIALIST
Imperial Health Plan of California
01.2020 - 12.2021
CLAIMS EXAMINER 3
North American Medical Management
01.2016 - 01.2020
APPOINTMENT CLERK
Kaiser Permanente Appointment Center
01.2011 - 01.2016
High School Diploma - GED
Citrus High