Medical Claims Analyst
NEXTCARE LLC
Total years of experience :7 years, 0 Months
Supervised the night-shift operations for the claims staff by establishing
priorities, reviewing, and analyzing, claims approvals and denials in
compliance with Claims Quality Standards and Adjudication rules
Checked into questionable claims to resolve errors and omissions.
Informs clients by explaining procedures, policy terms, and coverage.
Determine covered medical insurance losses by studying policy terms
and conditions.
Establishes proof of loss by studying medical documentation, assembling
additional information as required from outside sources, including claimant,
physician, employer, and hospital.
Observed inbound leads to address client satisfaction to surpass Net
Promoter Score expectations.
Determines eligibility by comparing client information to requirements.
Reviewed policies to determine appropriate levels of coverage and assist
with approval or denial decisions.
Calculate benefit due, initiate payment, or compose a denial letter.
Ensures legal compliance by following company policies, procedures,
Guidelines.
Maintains quality customer service by following customer service
Practices.
Protects operations by keeping claims information confidential.
Use contract notes to correctly apply group-specific classifications to
claims
Performed serological examinations using ELISA technique.
Writing and updating SOPs.
Assist in implementing, Correcting, and reinforcing of QC measures.
Perform urinalysis and stool analysis for detecting cyst and trophozoites
Performing AFB, India ink, PAS, Giemsa, Gram, and Romanowsky
staining technique for microscopic identification of germs.
Performing of CD4 counts to monitor levels of CD4 cells (T helper
cells).
Research on the serological prevalence of Hepatitis B and C co-infection
with Tuberculosis
Lean implementation, Six Sigma, process capability improvement, problem-solving, and data analysis backed by training in computer technology and Six Sigma methodology, to achieve significant improvement in critical business processes.
Cert II, in General Insurance with specialization in claims handling