michelle fajardo

* Entered all HCFA 1500 and UB04 data into the system * Determined coverage, if any, and the impact on the future coverage of the client * Cross referenced the insurance claim with the insurance policy to determine the value of the claim. * Communicated with our affiliates and customers to give them updates of the claims in process * Prepared monthly reports in Excel spreadsheets to show the increase of claims being paid and processed * Submitted more than 1,500 claims a month for reprising and authorized the release of payment. * Managed all incoming disputes, returned checks, and performed clerical duties such as fax, and email * Trained new Medical Claims Processors in all aspects of the job

* Uncovered thousands of fraudulent claims and provided evidence leading to the recovery of thousands of dollars in insurance over payments. * Analyzed and determined completeness and validity of claims. * Developed a strong understanding of NCCI and SCIO auditing * Applied over 200 provider refund checks biweekly * Conducted extensive research in order to obtain missing patient information on provider refund checks * Managed reimbursements of overpayments to providers * Identified projects to be worked on, developed action plans, and delivered projects by the targeted date * Responsible for analyzing, auditing, and investigating claim recoupments * Analyzed claims for data corrections * Reviewed critical errors from EDI submissions, research and correct data in the system. * Maintained good communication with providers

* Answered 80 to 100 provider phone calls daily and documented the information in QNXT * Maintained a good relationship with the providers * Revised HCFA 1500 and UB-04 claim forms and explain complex billing terminology in layman’s terms * Determined if the claims were paid correctly according to the Medicare and Medicaid Fee Schedule. * Reviewed the providers contract information * Provided appeal status and issue check tracer requests * Sent claims back to be reprocessed via SharePoint. * Advised the providers of timely filing limits and company procedures to dispute claims * Gave Medicare and Medicaid member eligibility as well as benefit information * Gave authorization status and fax over the authorization letters via Right Fax * Advised the providers of claim status information and fax EOB’s

* Responsible for running reports in Micro Strategy in order to identify/correct claims processing issues * Document, track, and resolve provider complaints * Review and correct encounter issues in order to receive funds from the state * Analyze and manually price claims based on pay class and/or DRG’s * Researched and reviewed Medicare, Medicaid, system work processes, plan business rules, and regulations in order to give the plans determination on paid, pended, or denied claims * Responsible for providing processing instructions to the claims department * Collaborated with various business units to resolve claims issues such as authorizations, compliance, or provider data management. * Analyze trends in claims processing issues * Responsible for manually calculating interest depending on insurance or provider error * Researched CPT, HCPCS, Rev codes, ICD-10, type of bill, etc… to ensure claims were being billed according to state and company guidelines * Review and analyze check runs, EOB’s, and EOP’s