Tiffany Sue
Ft. Lauderdale,FL
Summary
Organized and dependable Claims Examiner with over 14 years of experience. Thorough understanding of Healthcare Support, Benefit Specialist, Appeals, Auditing, Special Projects, and Corrected Claims. Detail oriented candidate successful at managing multiple priorities with a positive attitude while Willing to take on added responsibilities to meet team goals.
Overview
22
22
years of professional experience
Work History
Medicaid/Medical Claims Adjuster
CareFirst
11.2023 - Current
- Resolved complex claims issues for expedited processing and resolution.
- Verified insurance claims and determined fair amount for settlement.
- Identified insurance coverage limitations with thorough examinations of claims documentation and related records.
- Maintained compliance with state regulations and company policies while handling a high volume of insurance claims.
- Ensured accurate record-keeping within database systems for audit purposes and streamlined retrieval of pertinent information during claim reviews.
- Implemented quality control measures to reduce errors and improve overall accuracy rate in claims processing.
Claims Adjuster III
Tufts Health Plan
06.2021 - 12.2023
- QNXT & MACESS Claim Auditing & Reconciling, QA Reporting
- Claims processing for Medicare & Medicaid
- Special Projects
- Conducted thorough investigations of complex insurance claims, gathering evidence and analyzing relevant documentation.
- Evaluated coverage accurately by interpreting complex insurance policies and applying them to specific claim scenarios.
- Maintained compliance with state regulatory requirements through meticulous documentation and adherence to company policies.
Claims Adjuster III
Catalyst Solutions
08.2021 - 06.2023
- Claims Adjusting for Medicare & Medicaid claims in QNXT
- Special Re-work Project Team for corrected claims & Appeals
- Researched and analyzed policy contracts to verify proper payment of claims.
- Read over insurance policies to ascertain levels of coverage and determine whether claims would receive approvals or denials.
- Examined claims forms and other records to determine insurance coverage.
Benefit Verification Specialist
Amerisource Bergen
09.2020 - 05.2021
- Verifying Patient Benefits for Rx Drugs and Hone Infusion
- Verifying Patient Insurance Coverage
- Triage cases with missing or inaccurate information
Claims Examiner Lead
Anthem / Simply Health
06.2015 - 08.2018
- QNXT / MACESS Processing 160 claims in QNXT systems with 100% quality standards
- Auditing & reprocessing of Medicaid claims
- Managing Medicaid Daily & Weekly inventory reports
- Serve as a liaison between claims examiners and Managers
- Reduced claim processing time by implementing efficient workflow strategies and prioritizing tasks effectively.
Claims Liaison
Centene Corporation/ Kentucky Spirit Health Plan
07.2014 - 12.2014
- Processing Medicaid claims in accordance with AHCA and CMS guidelines
- Prepare, review and complete special claims projects impacting internal and external departments and/ or customers in accordance to company standards by targeted deadlines
- Review unpaid and overpaid claims
Post Judgment Legal Assistant
Choice Legal Group, PA
04.2012 - 02.2014
- Update, monitor and maintain LPS events for clients
- Responding to client inquiries and maintaining expected production level of 100-150 files daily
- Supported attorneys in achieving favorable outcomes through thorough research and analysis of complex legal issues.
- Increased client satisfaction by efficiently managing case files and promptly addressing inquiries.
- Facilitated timely resolution of legal matters by preparing and organizing essential documents.
- Maintained strict confidentiality, protecting sensitive client information as required by legal ethics and regulations.
- Enhanced office productivity by implementing efficient document management systems for easy retrieval and storage.
Furniture Expo Coordinator / Office Manager
Karel Exposition
01.2002 - 08.2010
- Managing in office & traveling staff
- Packing and shipping all required items for staff and displays
- Renewing lease and insurance contracts for convention centers
Education
Diploma -
Carol City Senior High
Miami Gardens, FL06.1999
Skills
- Leadership
- Effective Time Management
- Quality Control
- Computer Skills
- Ability to Work Under Pressure
- Data Entry Efficiency
- Attention to Detail
- Microsoft Office Proficiency
- Collaboration & Teamwork
- Insurance Claims Processing & Verification
- Strong Analytical Skills
- HIPAA Compliance Awareness
- Organizational Competence
- Insurance Policy Coverage Knowledge
- Complex Problem-Solving
Timeline
Medicaid/Medical Claims Adjuster
CareFirst
11.2023 - Current
Claims Adjuster III
Catalyst Solutions
08.2021 - 06.2023
Claims Adjuster III
Tufts Health Plan
06.2021 - 12.2023
Benefit Verification Specialist
Amerisource Bergen
09.2020 - 05.2021
Claims Examiner Lead
Anthem / Simply Health
06.2015 - 08.2018
Claims Liaison
Centene Corporation/ Kentucky Spirit Health Plan
07.2014 - 12.2014
Post Judgment Legal Assistant
Choice Legal Group, PA
04.2012 - 02.2014
Furniture Expo Coordinator / Office Manager
Karel Exposition
01.2002 - 08.2010
Diploma -
Carol City Senior High
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