Description
Career Highlights: I have 25 plus years of overall working knowledge of claims processing experience in both a client server and mainframe environment. I deal very effectively with all levels of staff and have excellent organizational and communication skills. I am extremely well organized and can handle multiple tasks and high volumes of data. My accomplishments include: * Accessing several database for data mining to prepare many Outbound Medical and Pharmacy files. Develop SQL queries and prepare test cases for both Medical Experience and EUAL testing at Highmark. * Develop and test an annual outbound file to CMS in order to provide claims data for end of year reimbursement of government subsided healthcare reform. * Data Model new access and code standardization tables * Worked on the manual processes necessary for three claims processing teams to be HIPAA compliant. * Worked on two re-engineering teams to change system templates for duplicate logic checking and call tracking functions for current claims processing system. * Corporate representative on a cross-functional team to evaluate multiple surgery guidelines and develop desktop procedures for provider billing guidelines for multiple surgery. * Department representative for off-site client's monthly meeting for our recruiting agency * Responsible for two payroll systems and numerous client excel/crystal reports for inventory control, claims management and payment management. * Oversee and explained benefit mapping issues for three claims processing teams. * Meet with auditors from three outside agencies to review end of line Quality Control audits and provide written documentation of audit results. * Responsible for leading the efforts for numerous projects and departments ranging in various staff sizes of up to 40 individuals. * Developed and performed reconciliation activities for operating budgets for the claims processing department. * Routinely led multiple projects simultaneously. * Participated in lead projects defined as critical in importance or those already in progress, which required immediate improvement. * Worked with Consultants to implement private business and Medicare Plus claims processing teams. Both teams process Professional and Facility claims through electronic transfer, paper and optical character recognition to image. * Prepare performance evaluations for 25-50 employees and provide feedback. * Helped with the testing of two claims processing systems for more involved claims types, such as anesthesia, Home Health and Therapy processing. * Prepare Decision Logic Tables used for processing claims. * Attended numerous Supervisory, Management and Leadership Seminars.
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