Antoinette McCaffity
Baltimore
Summary
Claims professional who values precision and efficiency in claims evaluation and resolution. Proven track record of managing high caseloads and settling claims accurately in compliance with company standards. Known for strong collaboration with team members and adaptability to changing needs, ensuring reliable performance and positive results.
Overview
8
8
years of professional experience
1
1
Certification
Work History
Claims Adjuster II
CareFirst BCBS
03.2024 - Current
- Addressed provider disputes efficiently, achieving a 1-day resolution time.
- Handled the reprocessing of 150-300 Medicare and Medicaid claims.
- Processed and settled complex claims, ensuring accurate payment or denial.
- Maintained accurate claims audit records through diligent data entry, verification, and security.
- Performed thorough investigations and adjustments of claims, maintaining compliance with guidelines and authority limits.
- Served as Subject Matter Expert and trainer for new hires, ensuring comprehensive understanding of claims processes.
- Assisted in the weekly audit of 50 claims, contributing to team efficiency and accuracy.
- Assessed and managed pricing and processing of ESRD and high dollar institutional claims.
- Managed the reissuing of checks, maintaining accuracy and efficiency in payment distribution.
- Responded to and assisted team members with complex issues, managing daily operations in the absence of the supervisor.
- Assisted with the processing of out of stat claims via Blue Square
- Processed out-of-state claims and determined pricing using Blue Square.
Customer Service Advocate II
Carefirst BCBS
09.2022 - 03.2024
- Monitored and resolved COB pends for EGWP.
- Addressed and managed escalated concerns from third-party representatives for member support.
- Supported special outreach initiatives for EGWP.
- Investigated and resolved provider disputes and appeals.
Cures Act Advocate
United Health Group
10.2020 - 03.2022
- Worked effectively with fellow team members to coordinate effective solutions to any question or concern.
- Managed complex caseloads with diligence, prioritizing tasks to ensure timely resolution of cases.
- Investigated escalated claim issues for Medicaid's 21st Century Cures Act Providers through comprehensive research.
- Coordinated and executed detailed reporting schedules for a designated territory of 12 states.
- Managed termination and potential termination processes for providers within assigned territory.
- Educated and trained providers on state Claims Logic.
- Analyzed and detected trends for states, working directly with configuration teams to address Mass state issues.
Network Service Specialist
United Health Group
01.2017 - 10.2020
- Resolved provider issues within a 2-day turnaround time through thorough investigation and research.
- Handled provider concerns and escalated issues for the Spectera vision network through effective email and outbound call communication.
- Utilized the ISET system to create and assign escalated issues to appropriate provider relation representatives.
- Facilitated the handling of contracts, reimbursement procedures, and rate agreements for contracted providers.
- Managed credentialing tasks for providers and new site locations.
- Troubleshot and resolved website portal issues, enhancing user satisfaction.
- Provided leadership and expertise to a team of network service specialists.
Education
High School Diploma -
Franklin High School
Reisterstown, MD06-2007
Skills
- Critical thinking
- Claims investigation
- Team collaboration
- Claims processing
- MS Excel
- Medical/Vision Terminology
- ISET
- FACETS
- BPASS
- Heath Rules
- WEB PRICER
- Blue Square
- VAS
- Salesforce
- CAQH
Certification
- Professional Scrum Master 1 Mar 2023
Timeline
Claims Adjuster II
CareFirst BCBS
03.2024 - Current
Customer Service Advocate II
Carefirst BCBS
09.2022 - 03.2024
Cures Act Advocate
United Health Group
10.2020 - 03.2022
Network Service Specialist
United Health Group
01.2017 - 10.2020
High School Diploma -
Franklin High School
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