Open To Work
TYNISA T. KNOX
Indianapolis,IN
Summary
Dependable, ability to adapt to new situations, willing to take on new tasks and responsibilities, perfect attendance, 100% quality results, ready and willing to do what it takes to get the job done.
Overview
28
28
years of professional experience
Work History
Claims Specialist 1
LTCG, Inc./Illumifin
2005.07 - 2025.10
- Under limited Supervision, adjudicate routine home and facility-based claims for LTC products, fairly and equitably within the contract parameters, and provide quality service to providers, agents, clients, and families.
- Performs a combination of the following duties according to departmental guidelines: Adjudicates routine home and facility-based claims for LTC products. Interprets and applies fundamental policy language to claim scenarios. Performs investigation and research on standard claims, including obtaining proof of loss. Escalates cases that are in need of investigation. Queries medical and service providers to obtain licensure information and proof of loss. Reviews claimant's diagnosis. Verifies the provider of care is appropriate and in accordance with contract language and government regulations regarding healthcare providers. Applies knowledge concerning state and federal regulations of the health-care industry, government-funded programs, and private insurance. Communicates with service providers regarding claim circumstances, including policy language and options available to the client. Handles consumer inquiries. Assist Claim Contact Center with Customer calls regarding claim benefits. Work standard operation reporting as needed. Communicates with Sr. Examiners and management on cases with special handling of non-routine claim situation. Determines benefit eligibility amounts based on policy language and internal procedures. Make suggestions to improve departmental workflow, processes and procedures. Other duties as assigned.
Claims Examiner
Blue Cross and Blue Shield of Illinois
1999.10 - 2005.07
- Screening, Examining, and adjudication of medical claims. Review and perform related duties.
- Determining primary diagnosis, select proper procedure codes to determine paid liability limit. Audit claims for validity errors, correct dollar amounts, and codes. Adjudicate claims using established procedures and codes. Determine need for and obtaining additional information from subscribers and/or providers. Processing of financial transactions through system. Determine primary coordination of benefits, reading medical records, prepare routine reports and maintain related files. Perform other duties as assigned. Knowledge in BlueCard.
Processor
Blue Cross and Blue Shield of Illinois
1998.03 - 1999.10
- Process paper and electronically submitted claim forms UB-92s and HCFAs inquiring investigation, phone calls, accessing resource materials and several other support files. Screen and edit claim data for accuracy and process for adjudication.
- Process claims on various work ques. Conduct research and investigation into missing information, make phone calls to providers, access resource material and other support files in order to process and adjudicate claims quickly and accurately. Responsible for adjustments and itemizations of claims. Perform other duties as required.
Education
Associate Degree - Applied Science
Danville Area Community College
01.1998
Diploma - undefined
Danville High School
01.1994
Skills
- Claims Quality Assurance
- Claims Processing
- Claims Investigation
- Microsoft Office/Outlook
- Policy Interpretation
- Settlement Determinations
- Documentation Review
- Claims Analysis
- Time Management
- Decision-Making
- Attention to Detail
- Teamwork and Collaberation
Timeline
Claims Specialist 1
LTCG, Inc./Illumifin
2005.07 - 2025.10
Claims Examiner
Blue Cross and Blue Shield of Illinois
1999.10 - 2005.07
Processor
Blue Cross and Blue Shield of Illinois
1998.03 - 1999.10
Diploma - undefined
Danville High School
Associate Degree - Applied Science
Danville Area Community College