1. Ann M Sutton
11505 Withersfield Dr.  St. Louis, MO 63138  (503) 333-8779  asapsnf@hotmail.com
Profile
Dedicated professional with more than ten years of experience investigating and processing
medical insurance claims. Excel in analyzing aged claims, interpreting policies and
negotiating payment solutions. Effectively manage multiple, high-priority projects and take
pride in providing exemplary customer/claim service.
Key Skills  Claims Handling and Investigations
 Risk Assessment and Mitigation
 ICD-9 & 10 CPT Assessment
 Medicare/Medicaid
 Proficient in: CPSS, Facets, ITS, Bluecard
 Claims Reports and Documentation
 Policy Interpretation
 Confidential Records Management
 HIPPAA Regulations
 Proficient in: Microsoft Excel, Word
Experience Blue Cross & Blue Shield – Portland, OR October 2005 – January 2013
Claims Service Liaison
Claims resolution point of contact utilizing all resources in the scope of being a Liaison to
consumer and third party entities. Analyze claims to determine extent of company’s liability,
make approvals or denial decisions and negotiate settlements with providers on behalf of
policyholders in accordance with policy provisions on aged claims. Collaborate with third
party agents and providers to correct errors, rectify omissions and investigate questionable
issues on complex/aged claims.
Accomplishments:
 Provided optimum service to policyholders, negotiated fair settlements/appeals and
identified fraudulent claims in a timely manner.
 Selected by supervisor to assistwith file closures on specialized claims unit; resolve
complex claims-processing issues; participate in quality-control audits; and monitor claim
status updates.
 Maintained a superior quality rating of 100% in file handling and claims resolution for
over 10 years, exceeding the 99% departmental goal.
 Received Quality Awards (2005-2013)/Service Excellence Award
Blue Cross & Blue – Portland, OR
Claims Processor I & II Adjuster
Supported claims adjusters in processing hundreds offirst- and third-party medical insurance claims.
Analyzed and determined completeness and validity of claims. Assisted policyholders in a busy call-
center environment. Processed claims from 4 to 22 claims per hour(depending on claim type and
department)
Accomplishments:
 Processed: Dental, Medical, Medicare, COB, and EMC’S for Federal Employees (FEP)
Programs. Processed ITS Home claims: Teamsters, PEBB, Nelson/TOC, WCIW, Regence-
TRG, KeyCorp, Willamette, Inland Boatman and Tri-met.
 Uncovered fraudulent claims and applied proper adjustments; provided evidence leading
to the recovery of thousands of dollars in insuranceoverpayments.
 Developed a strong understanding of insurance policies and legal issues through
completion of a series of insurance/ HIPPAA classes coupled with in-depth, multi-week
claims training.
 Graduated with Academic Honors
Education &
Training
St. Louis Community College (STLCC)-Associate in Applied Science degree, Human Services
Spokane Community College-Business Certification, Bancroft Center -- Spokane, WA
Training: Completed extensive training in ICD9/CPT, Medical Terminology,
Anatomy/Physiology, The Language of Medicine, Dean Vaugh’s Medical/Dental
Terminology & Skeleton and Communications, HIPPAA regulations; and Customer Service