Victoria Hill
Shelby Township,MI
Summary
With over 21 years of experience and 16 years with third-party administrators, I have a wealth of knowledge and expertise to offer. In addition, I am a self-starter with a positive attitude and the ability to provide sound suggestions for new processes or improvements
Overview
28
28
years of professional experience
Work History
Claims Operations Manager of Ancillary Department & Supervisor of Claims Operations
Allied Benefit
01.2021 - Current
- Responsible for interviewing, payroll, performance reviews, training, and staffing concerns
- The Training and development of new team members and ongoing departmental training
- Oversee daily operations and performance of the department
- Developed strategies to assist employees and enhance their performance levels while coaching and mentoring to help in the expert execution of claims
- Ensuring quality turn-around-time metrics are met and upheld
- Develop a new overpayment log and reporting system to provide accurate data for the refunds department
- Working with the Shared Administrations team internally and externally to ensure the line of business stays updated and runs smoothly, meeting all turnaround time and metrics established quality assurance program and metrics for the Allied Rapid Response Team and the Plan coders)
- Hands-on processing of high-dollar and complicated claims
- Worked hand in hand with Allied’s accounting department to reconcile five years of claims inconsistencies impacting the accounting department
- Oversaw the onboarding and new plan coding of over 100 new clients, ensuring that plans were built and audited promptly
- Assisted the supervisors of the Appeals and Subrogation departments in updating processes and developing those departments.
Senior Claims Analyst
ASR Health Benefits
01.2020 - 01.2021
- Quality assurance to ensure that the documentation is accurate and consistent
- Third-party claims processing knowledge
- Strong ability to pay, understand, and process according to plan guidelines efficiently and effectively prioritize work to meet goals and objectives within acceptable turnaround times
- Thorough knowledge of medical insurance claims procedures and documentation
- Communicating directly with client representatives and members to ensure a proper understanding of plan benefits.
National Refund Coordinator
BeneSys Inc.
01.2015 - 01.2020
- Established an internal Refund department within BeneSys, Saving hundreds of thousands of dollars annually
- Developed internal processes for collection, monitoring, and analyzing refunds
- Collaborated with BeneSys information and technology department to run critical reports that provided weekly updates to assist in reporting
- Applied analytic principles for reporting, organizing, interpreting, and communicating data related to the revenue cycle
- Managing all insurance overpayment requests
- Contact providers and discuss refunds and overpayment issues
- Helping to resolve billing issues and facilitate providers returning insurance overpayments
- Oversee management and training of refund procedures with claims staff nationally
- Provided expert consultation to leadership as the subject matter for the revenue cycle data and all refunds
- Streamlining and implementing best practices to allow refund processes to run smoother and more effectively, determining the “root cause” of overpayments by performing technical reviews of all claims needing refunds and collaborating with other departments to ensure proper training to avoid future overpayments
- Running weekly Excel reports for the executive team detailing current National Refunds, including Pivot tables and slicers
- Assisted in shared administration claims processing, invoices, and refunds.
Claims Analyst
United Healthcare Great Lakes Health Plan
01.2007 - 01.2013
- Medicaid claims processing knowledge, Strong ability to pay and understand ambulance with the exceptional ability to prioritize work to meet goals and objectives within acceptable time limits
- Thorough understanding of medical insurance claims procedures and documentation.
Home Claims Analyst
Automated Benefit Services
01.2005 - 01.2006
- Quality assurance to ensure that the documentation is accurate and consistent
- Independent claims processing with little supervision
- Ability to use independent judgment and to manage and impart confidential information.
Claims Analyst/Team Lead
NGS American, Inc.
01.2000 - 01.2005
- Consistently capture Summary Plan Benefits rules regarding subscriber liability, covered services, associated limitations, and maximums
- Advanced knowledge down to the code level of detail using custom applications
- Excellent multi-tasking, organizational, and follow-through skills with strict attention to detail
- Customer service skills, including phones, advised claims status, benefits, and processing guidelines
- Ability to build instant rapport with diverse individuals and accustomed to working in multi-cultural environments
- Analyzes to identify and resolve issues related to member benefit package information—research benefit information using various electronic sources
- Managed Medical Appeals, approved pre-determinations, and completed Medical Review
- Strong ability to gather data, compile information, and prepare reports
- Excellent records maintenance skills
- Team Lead responsibilities included Running Daily “LEAN” meetings
- To review and monitor, prioritize, and assign work to the staff to ensure the department meets the company claims turnaround
- During these “LEAN” meetings, I address issues and concerns and assign redistributed workloads to meet unit goals.
Billing Supervisor
Lakes Medical Billing
01.1996 - 01.1999
- Manage complex clerical and accounting functions for patient billing, including verifying invoice information and maintaining third-party billing records
- Consistent follow-up on submitted claims, patient billing, resubmitting claims, and resolving problems
- In-depth knowledge of medical billing procedures for submission of insurance claims: Medicare, Medicaid, and other private insurance carriers.
Education
Associate of Business Administration-Accounting -
Macomb Community College
Clinton Twp., MI01.2015
St. Clair High School
St. Clair, MI01.1996
Grosse Pointe North High School
Grosse Pointe Woods, MI01.1995
Skills
- Personal Health
- Health Insurance Portability and Accountability Act (HIPAA)
- Microsoft Office Proficient, Excel, PowerPoint, Word
- QuickBooks
- Medical software
- Facets
- Eldorado
- AS400
- QicLink 59
- Onbase
- DocuVantage
- Twenty-three (23) years of medical claims experience, including:
- Interpreting Medical Plan language (SPD)
- System analysis skills, Auditing, Training
- Calculations and adjustments
- Drafting Corrected Explanation of Benefits in Pdf
- Extensive PPO & SPD knowledge
- 5 Supervisory and Management skills
- Medicaid Claims knowledge
- Strong ability to interact and communicate with people over the telephone, often in stressful situations
- Exceptional knowledge of medical terminology
- Strong customer service skills
- Information (PHI)Demonstrated perfection (process claims one time only)
- Over 12 years working from home (remotely)
- 21 years of experience working for ERISA and TPA plans
- 8 years of Taft Hartley Funds experience
- 5 Years of Team Lead Experience (NGS)
- Five years Head of Refunds Department
- Administering Short Term Disability benefits
- Administering and processing HSA accounts
- Administered Death benefits
- Shared Administration processing and supervising
- Overpayment processing and Supervising
- Appeals and Medical Review Experience
Timeline
Claims Operations Manager of Ancillary Department & Supervisor of Claims Operations
Allied Benefit
01.2021 - Current
Senior Claims Analyst
ASR Health Benefits
01.2020 - 01.2021
National Refund Coordinator
BeneSys Inc.
01.2015 - 01.2020
Claims Analyst
United Healthcare Great Lakes Health Plan
01.2007 - 01.2013
Home Claims Analyst
Automated Benefit Services
01.2005 - 01.2006
Claims Analyst/Team Lead
NGS American, Inc.
01.2000 - 01.2005
Billing Supervisor
Lakes Medical Billing
01.1996 - 01.1999
Associate of Business Administration-Accounting -
Macomb Community College
St. Clair High School
Grosse Pointe North High School
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