Crystal Robertson

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OBJECTIVE 

Seeking a challenging position with a progressive organization that will fully utilize my acquired skills and experience.

KNOWLEDGE AND SKILLS

• Proficient in pricing of Medicaid Claims via Contract interpretation, GPD Facets NetworX platform, Medical Agreement Configurator, Price Calculation Summary, and Single Case Agreements.
• Extensive knowledge of Medical Coding and guidelines.
• Expert in both Facets & Amisys Claims Processing Systems and the Pega NextGen Appeals platform.
• Typing 35 WPM, Advanced 10 keying or other specialization.
• Proficient in Microsoft Access, Excel, Outlook, PowerPoint, and Word.   
• Knowledgeable using the RNF Database, CCert application.
• Skilled in Coordination of Benefits review, and strong research skills, and also in using the Knowledge Library.
• Strong attention to detail and extensive analytical/research skills.
• Competent, Knowledgeable, Self-Directed Learner with 10 plus years of Healthcare Industry experience, enhanced by Medicaid claim processing and medical coding training

CAREER HIGHLIGHTS

• Serving as the NY and MD Interim Team Lead since May 2016; training staff on new/modified reimbursement policies
• Previously qualified as a Telecommuter/Work@Home associate due to my ability to work autonomously while consistently meeting/exceeding production and quality metrics
• Assisted with a Peer to Peer (P2P) training program resulting in a 25% increase in new hire productivity and retention
• Assisted with testing of claims when an update has occurred with the multiple systems.

 EXPERIENCE

2006 to Current                      Anthem           Virginia Beach, VA.     

Provider Payment Reconsideration Analyst I

• Review and research provider claim Adjudication issues.
• Assist in the review of state or federal complaints related to claims.
• Suggest methods to reduce claims adjudication errors, thereby reducing provider complaints.
• Attend bi-weekly management meetings to review and discuss inventory trends.
• Follow-up with Management to address submissions that are inaccurate or missing pertinent documentation by requesting revisions to assist in executing strategic growth and development initiatives.

Claims Analyst II

Interim Team Lead NY and MD Market 

• Document, investigate, and facilitate the resolution of Medicaid claims adjudication issues using the Facets Claims Processing System.
• Utilize the interdependencies of various health plans and operational areas, such as benefits configuration, member enrollment, OHI verification, medical coding, provider information management, utilization management, etc. to properly identify the root causes of appeals issues and assist with resolution.
• Ensure correspondence to providers on grievance/appeals issues is clear and provides an appropriate resolution.
• Collaborate with Anthem team members to ensure the timely, and accurate submission of monthly, quarterly, and annual reporting requirements.
• Communicate effectively with internal and external customers by performing data entry into state tracking systems.

Claims Analyst I

• Assignments include preparing correspondence, maintenance of phone logs and contact logs, as well as project resolution for Maryland market.
• Extensive knowledge with regards to understanding and implementing appropriate claims processes and courses of action when adjudicating claims, to include the following (new day claims, claims requiring research, claims requiring adjustments and claims associated with other health insurance coverage).
• Suggests alternative ways to address issues encountered and guide these individuals to ensure they are in compliance policies and procedures

EDUCATION

(2020-Present) Old Dominion University Norfolk, VA. 23529

             Human Services

(2011) Medical Practice Management Associates Virginia Beach, VA. 23464

            Medical Coding Certification Course

(2005) Sentara School of Health Professions Chesapeake, VA. 23320

            Nursing Care Partner Certificate         

(2004) Virginia School of Technology Virginia Beach, VA. 23464

            National Certified Medical Assistant

(2002) Salem High School Virginia Beach, VA. 23464

            High School Diploma

References

Available upon request