Sarah Guinn
Memphis
Summary
I am currently an appeal auditor with many years of experience in the medical claims investigation/review area, specifically within UMR.
I'm very interested in learning a new role within our team and am able to adapt to a fast paced, ever changing work environment.
Overview
26
26
years of professional experience
Work History
Appeal Auditor
UMR
Collierville
03.2014 - Current
- 15+ years Experience working within UMR systems (Jacada, Onbase, Aerial, Knowledge Central, etc)
- Review and respond to written appeals by providers (or members)
- Complete research and gather claim and all other information pertinent to case to forward for medical review
- Complete documentation of review and respond to provider (or member)
- Ability to work and adapt in a fast-paced, ever-changing environment
- Ability to meet/exceed quality and production requirements
- Apply knowledge to solve common and complex problems
- Handle workflow queue via Onbase within expected timeframe
SIU Investigator
UMR
Cincinnati
03.2007 - 03.2014
- Investigate possible waste, error, abuse, and fraud leads
- Analyze claims payment to detect fraudulent provider practices
- Document activity on each case and escalate issues to the appropriate party or organization when necessary
- Request internal reports to identify potential waste, abuse, and fraud
- Apply knowledge to solve common and complex investigations
- Maintain confidentiality of sensitive information
- Perform medical record audits, and prepare and refer to RN for clinical review cases
- Handle workflow via Onbase and daily work report within required turnaround time
- Daily work performed in systems and application applications to include Claimfacts, CPS, Qiclink and Onbase. As well as Outlook Excel and Word.
- Initiate outbound phone calls to provider when necessary to gather information in order to complete review of case
- Return phone calls to members from fraud hotline in a timely manner
- Draft provider education letters
Medical Benefits Administrator
UMR
Cincinnati
09.2000 - 03.2007
- Process all medical claims and correspondence within required timeframe
- Payment threshold up to $25,000
- Ability to meet quality and exceed production standards
- Processing of inpatient claims
- Perform claim adjustments, including check, voids, refunds, stop payments, and check maintenance transactions
- Handle collection of overpayment and refunds
- Mentor new Benefit Administrators to the operations team
- Complete research and gather claim background relating to ERISA appeals
- Knowledge of complementing functions to include eligibility, utilization review, cobra, dental, flexible spending, cost containment, stop loss and appeals
- Answer incoming phone calls from providers, members and benefit representatives
- Make outgoing phone calls to obtain information necessary to finalize claims
- Promptly answer Internet request for information
- Create strong relationships, and work closely on a regular basis with Human Resources contacts
- Attend customer and employee meetings/benefit fairs along with members of management team
Data Entry Associate
UMR
Cincinnati
08.1999 - 09.2000
- Hand key claims received within required timeframe
- Regularly demonstrated the ability to meet and exceed quality and production standards
Education
High School Diploma -
Hamilton High School
Hamilton, OH 05-1997
Skills
- Claims analysis
- Appeals processing
- Fraud detection
- Documentation management
- Medical record auditing
- Data entry
- Regulatory compliance
- Workflow management
- Customer service
- Problem solving
- Research skills
- Effective communication
- Time management
- Team collaboration
- Clear communication
- Written communication
- Typing and 10-key entry
- Attention to detail
- Multitasking
Timeline
Appeal Auditor
UMR
03.2014 - Current
SIU Investigator
UMR
03.2007 - 03.2014
Medical Benefits Administrator
UMR
09.2000 - 03.2007
Data Entry Associate
UMR
08.1999 - 09.2000
High School Diploma -
Hamilton High School