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
Monterey park
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
Orange
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
Ontario
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