Dionne Baldwin

Experience

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  BLUE SHIELD OF CALIFORNIA/TELETECH

  Sept 2001 - Aug 2006

  Provider Service Advisor/Provider Claims Advisor

   GMIS, WGS, Nasco, ITS, HIQK & EDI Viewer Provided concise, quality customer service in a professional and courteous manner to national providers. Researched medical information to keep abreast of Blue Shield's various medical services. Established customer support to Blue's Shield other service centers in California. Assisted National providers and other "Blues/Athem" plans with claim status, adjustments, benefits & eligibility. Worked in the billing to department to key in manual claims Show less

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  Aetna, a CVS Health Company

  Aug 2006 - Apr 2008

  Quality Analyst for Aetna Workman Compensation Access

   Rumba Notebook & MCS Reviewed claims processed for Aetna's internal and external clients. Explored root cause for errors submitted by Aetna repricers.  Reported daily workflows for Aetna Workman compensation Access.  Provided superior customer service to Aetna providers.

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  The Jacobson Group

  Apr 2008 - Dec 2009

  National Account Representative

   WGS & Edi Viewer Provided Claims verification and adjustments  Assistant team lead Maintained interplan relationships within the 50 States including Puerto Rico for the Blues Organization Afforded quality customer service while aiding CO, NV & Blue Cross of CA providers in processing their claimsClaims Analyst IIICENTENE, Farmington, MO Amysis & Citrix Adjusted pended claims that needed additional consideration. Reviewed system generated pricing for accuracy Surpassed client’s company goals and expectations.Claims AdjusterPEACH STATE HEALTH SYSTEM, Smyrna, GA Amysis & Citrix Created Spreadsheets, PowerPoint presentations Reconciled newborn claims paid by Medicaid  Performed reconciliations on 2005 - 2007 claims paid by Peach State Health in error. Gathered Data and provided input on transitioning the workflow process. Show less

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  Dell Technologies

  Jan 2010 - Aug 2011

  Claims/Appeals Analyst II

   Facets & Macess Researched and adjusted Medicare appeals Priced HMO claims to pay according to contract Reviewed members benefits for pricingCOMMUNITY HEALTH PLAN OF WASHINGTON, Chicopee, MA Softeon, Xcelys, Edi Viewer, HIP & Knowledge Base Adjusted pended Medicaid claims for special release Researched root cause of held errors Reviewed the knowledge base to keep abreast of current changes

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  Kaiser Permanente

  Nov 2011 - now

  Senior Configuration Analyst

   Ensured Provider contracts are configured in Diamond accurately resulting in 100%claim payments consistent with the provider contractual agreements. Performed problem solving of configuration issues. Maintained detailed knowledge and understanding of Diamond rules relative to claims payment Used Macess workflow to monitor provider contract updates Analyzed provider contracts to determine the best approach to loading the information in to the claims system