Francine Martin4515 Windale Drive

Lawrenceville GA 30044Home 770-559-9096Cell 404-509-9173

Francinemartin2012@yahoo.com

OBJECTIVETo obtain a position where my skills will benefit my employer, and be part of an environment where I will be continually challenged. Extremely organized and highly motivated individual that works best in high paced/high demand environments while maintaining professionalism, time management, and prioritization of tasks at all times.

EXPERIENCE

1/13/2014-Present Magellan Health Services, Alpharetta GA

Claims Resolution Specialist Responsible and accountable for the accurate and timely processing of

adjustments, projects and administrative duties as required by the business unit(s). Must complete duties with a high level of detailed quality and professionalism. ESSENTIAL FUNCTIONS: - Adjudicate claims and adjustments - Assist in providing daily leadership for associates to obtain optimal results - Process adjustments to include tracking and trending performance of root cause analysis - Identify 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

7/19/2010-1/13/2014 Magellan Health Services, Alpharetta GA

Appeals CoordinatorMaintain caseloads and monitor day-to-day compliance of appeal decision time frames; Review inpatient and outpatient medical records and claims for completeness and determine administrative or clinical appeal; assigns clinical appeals to Physician advisors for medical necessity reviews; enter all data related to appeals and case reviews into a database. Participate in data gathering and analysis of reports regarding appeal activity as well as preparing for appeal audits, provide new employee training, monitors QI activities of appeals department, and assist in the development of department flows and implementations. Respond to member, provider, and client telephone inquiries regarding status, process, and outcome of appeals.

04/02/07-7/09/2010 United Behavioral Health, Atlanta, GA

Appeals CoordinatorInvestigating 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. Handle Medicare/Medicaid administrative appeals for members and providers. Handle Medicare/Medicaid clinical appeals for members and providers. Handle Medicare/Medicaid adverse determinations. Resolve claim issues and work 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.

06/20/05-04/02/07 United Behavioral Health, Atlanta, GA

Intake CoordinatorAssisting Members and Mental Health providers in obtaining Out- patient andIn-patient benefits as to what their policy will cover and confirming co-payment, coinsurance and deductible information. Assisting members and providers in obtaining Authorizations for out patient 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.

04/25/05-06/17/05 Placement Pros-United Behavioral Health

Intake CoordinatorAssisting Members and Mental Health providers in obtaining Out- patient and In-patient benefits as to what their policy will cover and confirming co-payment, coinsurance and deductible information. Assisting Members and Providers in obtaining Authorizations for out patient Mental Health Services and also locating local and national Mental Health providers.

01/03/05-04/21/05 Chase Staffing – Assurant Group

Mortgage Insurance Customer Service ProfessionalAssisting 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.

08/16/02-12/03/04 Empire BlueCross and BlueShield, Melville NY

Customer Service ProfessionalAssisting members with various policy information. Helping members with claim questions. Assisting members with benefit questions as far as what policy will cover.Assisting 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.

SKILLSMicrosoft Word, Microsoft Power Point, Microsoft Excel, Data entry, Claims Isets, IDRS System, Microsoft Publisher and Outlook

EDUCATIONAttended 2015-Present Strayer University, GAAttended 2008-2013 Troy University, Atlanta, GA Martin Van Buren High School, Queens Village, NY