Yudith S. Burres
Louisville,KY
Summary
Resourceful Hospital Claims Analyst professional promoting 12 years of expertise assessing coverage and overseeing claims review.
Overview
14
14
years of professional experience
Work History
Hospital Claims Analyst
MRA/Revecore
07.2015 - Current
- Identified issues, analyzed information, and provided solutions to underpaid or denied claims
- Conducted research, gathered information from managed care contracts to gain understanding of payment methodologies
- Researched specific medical records to expedited claim submission process
- Calculated medical claims reimbursement amount based on contracts terms.
- Identified insurance coverage limitations with thorough examinations of claims documentation and related records.
- Examined claims forms and other records to determine insurance coverage.
- Researched claims and incident information to deliver solutions and resolve problems.
- Read over insurance policies to ascertain levels of coverage and determine whether claims would receive approvals or denials.
Grievances and Appeals Production Lead
Humana Inc
06.2013 - 02.2015
- Supervised work of 10 - 15 associates to ensure resources were managed effectively to meet production and complete all tasks
- Used coordination and planning skills to achieve results according to schedule
- Completed paperwork, recognizing discrepancies, and promptly addressing for resolution
- Oversaw daily operations to ensure high levels of productivity.
- Supported employees by accurately tracking time and proactively resolving any conflicts.
- Communicated clear instructions for general operations to prevent errors and rework.
- Worked with supervisor and other team leads to manage and prioritize staffing assignments to meet customer demand and production schedules.
- Updated production metrics and facilitate regular team communication.
- Increased production targets by 15% by collaborating closely with team members.
- Prepared reports and technical documentation of day-to-day production processes.
Grievances and Appeals Specialist
Humana Inc
08.2009 - 06.2013
- Received and processed 20-25 customer grievances and/or appeals in a systematic and accurate manner
- Communicated professionally and empathetically with members to gather additional information and clarify their concerns
- Evaluated appeal documentation, ensuring completeness while adhering to industry regulations and compliance standards
- Ensured all grievances and appeal processes followed established guidelines and legal requirements
- Continually maintained quality and compliance scores of 98% or above
- Prepared and maintained accurate documentation for regulatory reporting and audits
- Analyzed grievances and appeals to determine appropriate courses of action for resolution
- Provided clear and concise responses to customers, explaining decisions and outcomes effectively.
Education
Associate of Science - Paralegal Studies
Sullivan University
Louisville, KY09.2016
Skills
- Customer Service
- MS Office
- Analytic Skills
- Written Communication
- Medicare/Medicaid Advantages programs (including Part D)
- Reimbursement Methodologies
- Facility Contract Interpretation
- Claims Investigations
- Medical Terminology
- Prior Authorization Processing
Languages
Spanish
Native or Bilingual
Timeline
Hospital Claims Analyst
MRA/Revecore
07.2015 - Current
Grievances and Appeals Production Lead
Humana Inc
06.2013 - 02.2015
Grievances and Appeals Specialist
Humana Inc
08.2009 - 06.2013
Associate of Science - Paralegal Studies
Sullivan University
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