Francine Martin is seeking a position utilizing her 14 years of experience in the healthcare industry processing claims and handling appeals. She has worked at Magellan Health Services since 2014 as a Claims Resolution Specialist and previously as an Appeals Coordinator from 2010 to 2014. Her resume details her roles and responsibilities in claims processing, appeals handling, customer service, and training for various healthcare companies since 2005.

1. Francine Martin
4515 Windale Drive
Lawrenceville GA 30044
Home 770-559-9096
Cell 404-509-9173
Francinemartin2012@yahoo.com
OBJECTIVE
To 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 Coordinator
Maintain 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.

2. 04/02/07-7/09/2010 United Behavioral Health, Atlanta, GA
Appeals Coordinator
Investigating 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 Coordinator
Assisting 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. 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 Coordinator
Assisting 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 Professional
Assisting 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

3. Customer Service Professional
Assisting 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.
SKILLS
Microsoft Word, Microsoft Power Point, Microsoft Excel, Data entry, Claims Isets,
IDRS System, Microsoft Publisher and Outlook
EDUCATION
Attended 2015-Present Strayer University, GA
Attended 2008-2013 Troy University, Atlanta, GA
Martin Van Buren High School, Queens Village, NY