Susan A. Sutton

lctrhu44@yahoo.com 505 Lodestone Drive (919) 928-6579 Durham, NC 27703

WORK EXPERIENCEWakeMed Hospital of North CarolinaFinancial Systems Analyst/Auditor for Patient Accounts, Raleigh05/2011 - Present

Use independent judgment and initiative to review, analyze and develop solutions for business systems

Identify, evaluate and resolve complex medical claim issues Responsible for processing override requests, resolving

customer complaints and provides excellent customer service to recipients and providers

Review, analyze, and follow-up on various facility/hospital claims that were received for non-payment

Lead department initiatives for analysis and development of business processes to ensure quality, cost effectiveness, timeliness of customer service, and regulatory requirements and mandates are met

Develop and prepare financial statements in accordance with existing requirements and company procedures to obtain the desired results Audit claims to help reduce operational losses resulting from policyholder fraud or deceit. Reviews requests for reimbursement that the insurer receives and ensures that such requests are valid Ensures claims for policyholders are processed accurately and are valid based on the member’s benefits and pricing. Applies generally accepted auditing standards (GAAS) to confirm correctness of claim amounts. Provide comprehensive functional, regression and integration testing for internal controls Track and prioritize defects with project team & business owners and work with developers to resolve any test failures related to financial inconsistencies Provide excellent customer service to providers and patients Function as a liaison to IS, other department system analysts and vendors Support projects to improve processes/controls, partner with

project teams to ensure resolution of project/post-project issues and participate on cross-functional projects as a finance representative

Use GAAP and SAP extensively daily

I have over 9 years of experience in accounting, auditing concepts and financial analysis. Great leadership skills, teamwork and medical background I have 27 year experience in HealthCare Claims field processing claims, Adjusting, Following-up, Corrected Claims, UB04, HFCA, and Coding, split billing, moving charges and Billing.

EDUCATION/CERTIFICATIONS: Master’s Degree in Business / HealthCare Administration August 2010 Pfeiffer University Bachelor of Science in Accounting May 1982 Shaw University Certificate in Software ApplicationsJune 1988 National Education Center Member of Associate of Certified Fraud Examiners (ACFE )

SYSTEM QUALIFICATIONS: Test Director/Quality Center SharePoint 2007 Microsoft Word Visio PowerPoint Excel Legacy Siebel LawsonApplication Software PowerMHS ITS-mainframe system Service First Pega-WS+ Blue Squared

Plan to Plan communication Facs Trac BlueE Mobius

SPECIAL ACCOMPLISHMENTS: Assigned to work on a special project called: Out of Balance Report for voucher deducts/credit memos – resolved a large dollar amount of mismatch finance dollar amounts for reconciliation Worked on Aged Financial Recovery Report – resolved over 50+ claims to meet departmental goals

Balance patient accounts after insurance company has paid and contract discount has been taken Train new hire employees on various types of coverage/line of business Commercial, State,

Individual, ASO, and Coordination of Business Medicare Coverage Follow-Up

Timely identify and obtain information and records from customers, members, providers and/or employer groups to correct/update information, claims and membership records when necessary

Recognize patterns of inconsistent and/or inaccurate claims filing practices among customers and providers, educate customers and providers

Three Year Experience on Palmetto GBA- (Medicare) Access eService’s – which allow free internet based, provider self-service portal. Shows the Electronic data interchange (EDI) enrollment of Medicare. Access give to the Medicare recipient eligibility or claims status

Access to NcTracks for Medicaid Recipients to be able to research NC tracks database to make a person coming into WakeMed has Medicaid. We can examine the data provides the online enrollment application and a checklist of Provider Qualifications and Requirements

Blue Cross and Blue Shield of North CarolinaFinancial Recovery Analyst, Chapel Hill11/2008 - 04/2011

Acted as a single point of contact for internal and external customer inquiries Processed a variety of complex customer financial using the Lawson Software Application Assisted the business area in balancing patient financial claims and assisted in auditing of

claims payment Assisted the testing area in creating test scripts for Lawson testing pertaining to upgrades Post Provider payments in regards to refunds and adjustments Informed customers about the status of their inquiries Analyzed internal and external adjustments to complete prior claim transactions by reflecting

the appropriate certificate liability Identified and analyzed opportunities for improvements in financial processes, policies and

services Provided great customer service to 40 clients daily Processed credit memos, payments and voucher deducts in Lawson Processed correspondence, stop-payments/re-issues and Service First Identified trends and suggest ways to achieve optimum accuracy Used and navigated Power Manage Healthcare Systems for claims Maintained familiarity with BCBSNC policies, claims and membership procedures

Blue Cross and Blue Shield of North CarolinaAdjuster- Inter-Plan Programs, Durham 8/2006 - 11/2008Claims Adjuster, Durham 9/2003 - 08/2006Blue Card Examiner/Claims, Chapel Hill 6/1997 - 12/1997

Well Path/Coventry Senior Service Operations Specialist, Chapel Hill 12/1998 - 9/2003

Wake Med HospitalOutpatient Biller, Raleigh 12/1997 - 12/1998

Systems Used:EPIC (Electronic Privacy Information Center ), SMS (Short Message Service) –Communication infrastructure, MedAssets-revenue cycle management software, Windows Vista, Mac Osx, Microsoft Applications (Excel, Access, Word), Inter-Plan Programs=IPP out of state claims system application used= BlueSquared-claims apps, Blue-E-claims electronic exchange, Citrix, PowerMHS-claims, Magic-holds member’s benefits for IPP claims.