sarah watson

*  Ensured that qualification requirements were met. *  Obtained verification documents from potential enrollees *  Made enrollees aware of ongoing program requirements *  Set up the individual or group enrollees in the system so that program benefits could begin. *  Primary point of contact for new enrollees. The person of whom the majority of questions are asked. Maintained good understanding of the federal and state rules governing these programs and of the enrollment requirements for different situations in order to answer questions completely and correctly the first time.

 Resolved all system errors, holds and pends to complete accurate adjudication of required adjustments for Medicaid claims  Trained adjusters in the cob process. Provided retraining for claim reversals, creation of uplettered claims (adjustments), and the correct claim documentation for adjusted as well as non-adjusted claims.

*  Resolved all system errors and pends to complete accurate adjudication of all claims involving coordination of benefits (including COB, FEP, Direct/Self pay, and Medicare) *  Monitored completion of work assignments and assisted with complex claim issues *  Chaired team meetings held for training/feedback purposes

 Resolved complex claims issues (e.g., member and provider inquiries, appeals & grievances) involving all commercial products as well as Medicare/Medicare Advantage benefit policies (which may or may not have required adjustments and/or back-outs/reversals)  Queried claim data to identify overpayments and underpayments, and initiated refund requests or additional payments, as indicated  Resolved system errors/defects to release claims which failed auto-adjudication

 Resolved complex claims issues (e.g., member and provider inquiries, appeals & grievances)  Queried claim data to identify overpayments and underpayments, and initiated refund requests or additional payments, as indicated

 Resolved complex claims issues (e.g., member and provider inquiries, appeals & grievances) involving all commercial products as well as Medicare/Medicare Advantage benefit policies (which may or may not have required adjustments and/or back-outs/reversals)  Queried claim data to identify overpayments and underpayments, and initiated refund requests or additional payments, as indicated  Resolved system errors/defects to release claims which failed auto-adjudication

*  Queried claim data to identify overpayments. Initiated refund requests. *  Monitored completion of work assignments and assisted with complex claim issues ((e.g., member and provider inquiries, appeals & grievances) *  Responsible for distribution of work assignments to adjusters and monitored daily production statistics to insure production goals were met. *  Completed claim work flow projects, audits, and provided feedback to management team *  Resolved complex financial recovery issues *  Processed, coded, voided and adjusted claims for all commercial products and lines of business (including ASO/Non ASO, Direct/Self-pay, as well as Medicare and Medicaid