Alaya Stove
Houston,Texas
Summary
Seasoned Senior Medical Claims Examiner with comprehensive experience in processing complex healthcare claims. Exceptional skills include accuracy, strong analytical abilities, and comprehensive knowledge of medical terminology and coding procedures. Previous work has resulted in streamlined processes for efficient claim handling and reduced errors.
Analytical professional in the insurance investigation field known for high productivity and efficient task completion. Skilled in claim evaluation, fraud detection, and regulatory compliance, ensuring thorough and accurate case handling. Excel in communication, problem-solving, and decision-making, leveraging these soft skills to navigate complex cases effectively and deliver optimal outcomes.
Overview
5
5
years of professional experience
Work History
Senior Medical Claims Examiner
NTT DATA Services
Houston, Texas
03.2023 - 08.2024
- Reviewed and evaluated medical claims for accuracy and completeness according to established policies and procedures.
- Identified discrepancies in medical claims, contacted providers or other personnel as necessary to resolve issues, and corrected errors.
- Analyzed provider contracts, fee schedules, and reimbursement methodologies to determine correct payment amounts.
- Coordinates with other departments to ensure appropriate claims transition or facilitate timely return to work.
- Grievance Coordination: Process Medicare customer grievances by screening incoming complaints, conducting root cause analysis, creating action plans, coordinating, and communicating resolutions, and documenting detailed case notes in compliance with CMS guidelines.
- Correspondence: Engage with members, providers, and regulators to communicate decisions and actions effectively.
- Collaboration: Work closely with Claims, Customer Service, Appeals, and Medical Management Departments
- Summary Skills Experience Compliance: Ensure adherence to all Compliance/Program Integrity requirements and comply with HIPAA Regulations.
- Professional Growth: Promote individual development through mandatory and continuing education and skills competency. Departmental Support: Contribute to department-based goals to drive organizational success
Claims Benefit Specialist
BroadPath Healthcare
Atlanta, Georgia
03.2021 - 03.2023
- Reviewed and evaluated customer claims for accuracy, completeness and compliance with company policies.
- Compiled data from various sources to assess benefit eligibility and entitlement.
- Documented claim processing activities in accordance with established procedures.
- Analyzes and approves routine claims that cannot be auto adjudicated.
- Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and applies all cost containment measures to assist in the claim adjudication process.
- Proofs claim or referral submission to determine, review, or apply appropriate guidelines, coding, member identification processes, provider selection processes, claim coding, including procedure, diagnosis and pre-coding requirements.
- May facilitate training when considered topic subject matter expert. In accordance with prescribed operational guidelines, manages claims on desk, route/queues, and ECHS within specified turn-around-time parameters (Electronic Correspondence Handling System-system used to process correspondence that is scanned in the system by a vendor). - Utilizes all applicable system functions available ensuring accurate and timely claim processing
Fraud and Risk Analyst
US Bank Service Center
Houma, Louisiana
06.2019 - 03.2021
- Handle inbound member calls in a fast-paced contact center environment
- Use effective communication probing questions and critical thinking skills to identify member needs and provide relevant solutions which may include offering banking products
- Efficiently navigate multiple systems and programs while maintaining an engaging member interaction that may occur across multiple channels.
- Develop banking product knowledge to attract new members and expand relationships with current members through product acquisition
- Analyzed and monitored customer accounts for suspicious or fraudulent activity.
- Investigated and reported on potential fraud cases.
- Developed risk mitigation strategies to reduce the likelihood of future fraud incidents.
- Reviewed financial documents for discrepancies or irregularities related to fraudulent activities.
- Analyzed data from multiple sources such as credit card companies, banks, and payment processors for suspicious activity.
- Communicates with members by phone or email to validate account activity
- Determines existing fraud trends by the analysis of accounts and transaction patterns
- Maintains a strong knowledge of the financial industry and complies with all applicable rules and regulations required within the scope of duties, including, but not limited to, the Bank Secrecy Act and the Uniform Commercial Code.
- This position is responsible for processing customer transactions and researching and resolving customer inquiries by completing maintenance on BankUnited's customer service applications
- Maintains call productivity & quality scores well above minimum standards
- Acquires, demonstrates and utilizes knowledge of Retail, Online banking, Mortgage and Business product expertise
- Provide outstanding member service by demonstrating empathy, active listening, and professionalism
- Apply strong time and call management skills in assisting members with banking needs
- Embrace continuous improvement and development through coaching and collaboration with manager and team members
Education
Associate of Applied Science -
Baton Rouge College
Baton Rouge, LA04-2024
High School Diploma -
Terrebonne High School
Houma, LA05-2018
Skills
- Analytical Problem Solving
- Insurance claims management
- Quality assurance checks
- HIPAA
- Data Entry
- Medicaid/Medicare
- Medical Terminology
- CRM Software
- MS Office
- Data Verification
- Customer Service
- Claim Form Analysis
- Active Listening
- Claim processing
- Team collaboration
- Liability Determination
- File and Record Management
- Settlement Negotiations
- Critical Thinking
- Attention to Detail
- Multitasking
- Dual Monitors
- Remote Office Ability
- Conflict Resolution
- Epic/Salesforce
- Insurance Claims
- Hospital Claims
- Longterm-care Claims
Timeline
Senior Medical Claims Examiner
NTT DATA Services
03.2023 - 08.2024
Claims Benefit Specialist
BroadPath Healthcare
03.2021 - 03.2023
Fraud and Risk Analyst
US Bank Service Center
06.2019 - 03.2021
Associate of Applied Science -
Baton Rouge College
High School Diploma -
Terrebonne High School