Fund (SCIF) Maintained daily accounts receivable and accounts payable review of disputed medical claims. Managed consistent written and verbal communication between members, providers, and corporate associates regarding case file review and final determination of medical benefits available through the schedule of benefit/health plan. Lead cost reduction and process improvement projects resulting in improvement in department operations. Reviewed and verified claim accuracy through cross referencing the claim CPT codes with the policy and procedures to determine the cost associated with the claim payment. Adjusted claims and evaluated the account payable or account receivables of medical claims based on the contract agreement of the provider. Reviewed and evaluated provider contract agreements and processed claims according to the agreement percentage rate indicated in the contract for the claims submitted. Recouped claims that were deemed to be over paid after the claims adjustment evaluation. Redeemed recouped funding through claims collections. Evaluated and reported suspicious and fraudulent claims based on the insurance regulation laws and requirements. -Analytical and payment accuracy review of medical files, forms, claims -Medical coding/claim form knowledge, ICD-9 coding, HCPC/CPT coding, UB92/UB04/HCFA forms -Product knowledge of PPO, HMO, IFP, FLEXNET, MEDICARE, MEDICAL, FIRST HEALTH, HOME HEALTH, CSP, HEMO/CHEMO, SPECIALTY PRODUCTS Managed daily overview of medical insurance claim submissions of workers compensation cases through review of medical necessity of services rendered. Determined financial responsibility and accounts receivable/payable of services approved. Manual data processing and accuracy review of medical claims. Evaluated and reported suspicious and fraudulent claims based on the insurance regulation laws and requirements. -Analytical and payment accuracy review of medical files forms claims -Medical data accuracy confirmation of ICD-9 coding HCPC/CPT coding UB92/UB04/HCFA forms (home office) Managed private field workers compensation claims investigation focused on direct communication with claimants and insured clients. Maintained communication related to case developments and discoveries determined through the investigation process. Lead stake-out/sub-rosa on site investigation of claimants and recorded video documentation of daily activity. -Determined medical necessity of injuries through face to face and telephone recorded statements -Wrote detailed reports of investigation overview/ field video documentation -Managed high volume case load and consistency (Case volume included traveling Northern.CA region) Managed day to day customer relationships specific to property and casualty losses and claim submission review. Performed extensive explanation of coverage of policy allowance/limitation. Immediate extensive response to policy inquiry and financial responsibility. Conducted recorded statements to determine liability percentages and responsibilities of the claimant and insured. Maintained case review and completion of property loss assessments. Lead team goal and accountability score for two months. -Managed auto and property claim loss assessment with a case load of 250 or more -Determined financial responsibility and percentage of liability based on recorded statement Managed day to day customer relationships specific to property and casualty losses and claim submission review. Performed extensive explanation of coverage of policy allowance/limitation. Immediate extensive response to policy inquiry and financial responsibility. Conducted recorded statements to determine liability percentages and responsibilities of the claimant and insured. Maintained case review and completion of property loss assessments. Lead team goal and accountability score for two months. -Managed auto and property claim loss assessment with a case load of 250 or more -Determined financial responsibility and percentage of liability based on recorded statement

Highlights:

Companies I like:

healthnet, blue shield, blue cross blue shield, centene, united healthcare, liberty mutual

• Accounts Payable
• Accounts Receivable
• Benefits
• Coding
• ICD-9
• Process Improvement
• Chip Scale Packaging (CSP)
• Csp
• Home Health
• Insurance