Waketsha Guye

• Facilitated data entry and management for internal reporting systems to enhance reporting accuracy.
• Provided training and guidance to staff on operational procedures, policies, and regulations.
• Reviewed existing operations processes for accuracy, timeliness, and adherence to internal guidelines.
• Executed UAT and regression testing for business systems utilized in claims adjusting, ensuring system reliability.
• Adjusted health insurance claims for the correct payment amount to consumers.
• Managed a secure mailbox used to help claim processors complete their daily assigned work cases.

Identified and retrieved incorrectly paid funds from vendors, improving financial accuracy.

• Audited claims for overpayments and corrected billing discrepancies across medical policies and coordination of benefits
• Processed refunds from providers due to overpayments, contributing to financial integrity.
• Coordinated with departments for comprehensive account management, enhancing overall recovery processes.

• Conducted vendor audits ensuring compliance with quality standards.
• Audited claims that had over-payments and were data-mined by a third-party vendor.
• Managed claims that were received in the high dollar queue
• Spearheaded initiative for improved database to validate claims, enhancing speed and access for peers and management.
• Developed desktop procedures (DTP) for auditors, operation specialists, and business analysts to maintain key performance indicators (KPI).

• Please refer to the duties that are listed below for the same role.

• Reviewed and analyzed claims, ensuring compliance with company policies and reducing potential errors.
• Collaborated with healthcare providers to effectively resolve claim disputes, improving resolution timelines.
• Reviewed, evaluated and processed incoming claims to determine eligibility for coverage based on policy provisions.
• Ensured compliance with laws, regulations, and policies during claims processing.
• Documented claims resolutions and maintained accurate records.
• Adhered to established workflow processes and timelines in order to meet performance goals.
• Monitored reports to identify claims issues and coordinated with adjusters to facilitate timely problem resolution.

• Assisted customers with inquiries about insurance plans and benefits, ensuring clear understanding of options available.
• Resolved complex problems by working with other departments to provide solutions that meet customer needs.
• Maintained detailed records of customer interactions and transactions to support effective follow-up and service continuity.
• Resolved complex problems by working with other departments to provide solutions that meet customer needs.
• Managed customer incentive plan to encourage members to engage in physical activity through the Blue Points program.