Francine Martin4515 Windale Drive

Lawrenceville GA 30044Home 770-559-9096

Francinemartin2012@yahoo.comwww.linkedin.com/in/FrancineMartin

Summary

Dynamic, detail oriented, organized, efficient, and results driven professional with over 12 years expertise in the Healthcare Insurance industry seeking a position in Account Management, Client Relationship, and Case Management. Expertise in claims payment, adjudication, and auditing all while maintaining a high level of professionalism, productivity, and efficiency; respond, resolve, and follow up on critical claims payment issues to ensure complete satisfaction and adherence to state and federal payment guidelines.

Time Management Relationship ManagementCase Resolution Issue TroubleshootingCare Management Commercial Insurance ExpertCase Management Employee Training

Proficient Technological Experience

Microsoft Office (Word, Outlook, Excel, PowerPoint, Access, Publisher) Data entry, Claims Isets, IDRS System, Citrix, Facets, Sharepoint, AUD, ICD9, ICD10, AS400, WebEx, Meet Up, Workday, Nasco, FEP Direct, Mimosa, Avaya, Web Checks, SABA, Lotus Notes,

Professional Experience

MAGELLAN HEALTH SERVICES, Alpharetta GA 2014-Present

Claims Resolution Specialist | January 2014- PresentServes as the resident claim functional expert within the Care Management Center (CMC) that utilizes expertise to aid interdepartmental staff in the interpretation of claims payment and problem resolution for excessive and escalated claim issues that are outside the scope and complex in nature. Frequently called upon by the Learning and Development Team, Supervisors or others in the CMC to aid in CMC education activities.

Responsible and accountable for the accuracy and timeliness of processing adjustments, projects, and administrative duties as required by the business unit(s) while completing duties with a high level of detail, quality, and professionalism.

Oversee claim adjudication and adjustments which lead to minimization of inaccurate claim payments. Assisted in providing daily leadership for associates to obtain optimal results. Performed tracking and trending root cause analysis that led to an overall reduction in company spend. Identified system benefit errors completing protocols and workflows to prevent future errors Handle all types of requests, inquiries and complaints accurately and timely Provide re-enforcement training for new associates as required as well as on floor support for existing

associates Respond to written correspondence and phone inquiries from internal customers Assist with handling internal routes (rates, provider membership issues) Seek, gather and analyze relevant data to address problems effectively Federal cases

Senior Appeals Coordinator | July 2010- January 2014Maintain caseloads and monitor day-to-day compliance of appeal decision time frames

Audited inpatient and outpatient medical records and claims for completeness and accuracy. Determine administrative or clinical appeals; assigned clinical appeals to Physician advisors for

medical necessity reviews Entered all data related to appeals and case reviews into a database. Participated in data gathering and analysis of reports regarding appeal activity as well as preparing

for appeal audits, provided new employee training, monitors QI activities of appeals department, and assisted in the development of department flows and implementations.

Responded to member, provider, and client telephone inquiries regarding status, process, and outcome of appeals.

UNITEDHEALTH GROUP, ATLANTA GA 2005-2010

Senior Appeals Coordinator | April 2007-July 2010Investigating member’s medical records as to why claims for inpatient or outpatient services were not paid.

Working side by side with Doctors in finalizing determination of claims payments. Working with Mental Health and substance abuse claims, appeals, and adverse determinations. Handled Medicare/Medicaid administrative appeals for members and providers. Handled Medicare/Medicaid clinical appeals for members and providers. Handled Medicare/Medicaid adverse determinations. Resolved claims issues and worked with medical directors to get clinical rationales. My responsibilities included mentoring, training for new hires and seasoned staff and a host of

other special projects.

Intake Coordinator | April 2005-April 2007Assisting Members and Mental Health providers in obtaining Outpatient and Inpatient benefits as to what their policy will cover and confirming co-payment, coinsurance and deductible information.

Assisting members and providers in obtaining Authorizations for outpatient Mental Health Services and also locating local and national Mental Health providers. My responsibilities included mentoring, training for new hires and seasoned staff and a host of

other special projects.

CHASE STAFFING/ASSURANT GROUP, ATLANTA GA 2005

Mortgage Insurance Customer Service Professional| January 2005-April 2005Assisting Insurance Agents and also customers in making sure that annual home owners, flood and wind policy premiums are paid. Also making sure that policy information is current and updated.

EMPIRE BLUECROSS AND BLUESHIELD, Melville NY 2002-2004

Customer Service Professional| August 2005-December 2004Assisted members with various policy information. Helping members with claim questions.

Assisted members with benefit questions as far as what policy will cover. Assisted members with locating local and national providers. Recycling claims to pay out. Sending letters to providers. Confirming co-payment and coinsurance

and deductible information. Sending out identification cards and provider directories.

Education

Bachelor of Business Administration Concentration in Health Administration, Strayer University

Expected Graduated May 2018