JADE JOHNSTON
Belmont,NC
Summary
Effective Medical Claims Processor with strong background building rapport with providers to discuss claim status or claim denials. Driven performer equipped to handle multiple administrative tasks effectively. Exemplary worker with highly investigative skills when processing claims.
Overview
10
10
years of professional experience
Work History
REMOTE PROVIDER DATA AND ENROLLMENT SPECIALIST I
Healthcare Consultants
Belmont , NC
12.2023 - 10.2024
- Wintegrate [CSC] system provider
- Associating providers to TIN
- Credentialing, Payment Systems
- Provider Network, Contract data processing provider termination
- Researching and resolving provider set ups
- Terming provider contacts
- Manual Adding LOBs {Lines of Business}
- Provider Contract Fulfillment
- System use {Maces, Change Gear, SharePoint Wintegrate}
- Data Entry and understanding of provider configurations
REMOTE GRIEVANCE APPEALS SPECIALIST
Molina Healthcare
Belmont, NC
07.2022 - 12.2023
- Enhanced grievance appeals efficiency by streamlining processes and implementing best practices
- Reduced case backlog significantly through diligent review and resolution of pending grievances
- Improved customer satisfaction rates by providing timely and empathetic responses to appeals inquiries
- Conducted thorough investigations for complex cases, ensuring fair and accurate outcomes
- Production 25 to 38 cases daily
- No surprises Act - Process appeals sent in by doctors against hospital decision
- Follow Hippa guidelines
- CMS website is a toll utilized on a daily basics to preform job responsibilities
REMOTE CLAIMS ANALYST
NTT DATA Services
Charlotte, NC
12.2019 - 07.2022
- Review and analyze historical medical claims, accurately mapping CPT codes to specific services, procedures, and diagnoses
- Identify trends and patterns in claims data to understand population health, healthcare utilization, and cost drivers
- Understanding and Processing using ICD-10 and ICD-9 code lookups
- Process routine medical, dental and/or hospital claims in accordance with assigned Plan(s)
- Processed 80-150 claims per day depending on medical queues
- Conducted thorough claims investigations to identify customer claims
- Prepare files for loading onto claims platform (Xcelys)
- Pull/ Load professional contracts into Xcelys through appropriate research and provider data load activities
- Qnxt Role
- Load provider files and audit completion
- Reviewing and researching insurance claims to determine possible payment accuracy
- Validating Member, Provider, and other Claims information
- Understanding medical terminology
- Quality Auditing
- Inpatient claims processing
REMOTE CLAIMS TECHNICAL REVIEW
Zenith American Solutions
Charlotte, NC
08.2018 - 12.2019
- Process routine medical, dental and/or hospital claims in accordance with assigned Plan(s)
- Processed 80-150 claims per day depending on medical queues
- Knowledge of Medicaid and Medicare process
- Provide customer service by responding to and documenting telephone and/or written inquiries
- Consistently meet established performance standards, including quantity and quality claims processing standards
- Maintain current knowledge of assigned Plan(s) and effectively apply knowledge in payment of claims, customer service, and all other job functions
- Provide back-up on other accounts as necessary
- Consistently demonstrate excellent attendance and punctuality
- Perform other related duties as assigned
REMOTE CLAIMS PROCESSOR
Anthem Inc.
Charlotte, NC
06.2014 - 12.2017
- Remote Process medical claims for state of TN, FL, LA, KS Use Citrix
- Facets Production 122-160 day
- Review insurance policy terms to determine whether loss is covered by insurance
- Quality Auditing -Assist in analysis of target audits as required
- Resolved problems, improved operations and provided exceptional service
- Oversaw daily operations to ensure high levels of productivity
- Followed up on potentially fraudulent claims initiated by claims representatives
- Collaborated with claims department and industry anti-fraud organizations to resolve claims
Education
Associates - Business Administration
Central Piedmont College
Charlotte, NCSkills
- Xcelys
- Quality Auditing -QA
- QNxt
- Facets
- SQL
- SAS
- CAQH
- Infocus / System
- Change Gear
- Maces
- Web Facets
- Contract System
- HealthAxis
- CMS
- Provider Contract Fulfillment
- AS400
- Utilization Management
- Provider Enrollment
- WinteGrate CSC
Timeline
REMOTE PROVIDER DATA AND ENROLLMENT SPECIALIST I
Healthcare Consultants
12.2023 - 10.2024
REMOTE GRIEVANCE APPEALS SPECIALIST
Molina Healthcare
07.2022 - 12.2023
REMOTE CLAIMS ANALYST
NTT DATA Services
12.2019 - 07.2022
REMOTE CLAIMS TECHNICAL REVIEW
Zenith American Solutions
08.2018 - 12.2019
REMOTE CLAIMS PROCESSOR
Anthem Inc.
06.2014 - 12.2017
Associates - Business Administration
Central Piedmont College
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