1. Tonja Boyd
1083 CardinalSt NW
Salem Oregon 97304
(503)507-6624
tongaboyd@gmail.com
______________________________________________________________________________
Job Objective:
 Obtain gainful employment
Highlights of Qualification:
 20+years billing/coding experience in both workers compensation and
regular medical insurance.
 I learn very fast and am willing to take on new challenges
 Flexible, willing to work when needed. Able to multitask, and am friendly and easily
work well with others.
 Always looking for more ways to learn and expand my knowledge base through
continuing education, classes, conferences, and certifications.
 I am very detail oriented and analytical
Professional Accomplishments
 Acquired and maintained my Oregon Worker’s Compensation Claims Examiner
Certification through renewal credits and ongoing education 1999 to present.
Work History
 PH Tech (Performance HealthTechnology)/ExpressPros –December 2014
to September 2015:
o Claims Specialist
o Pacificsource, Familycareand Willamette Valley Community Health
claims processing.
o Responsible for the processing of basic and specialty claims, provider customer
service, accounting runs, special projects and other functions.
o Maintain orderly and systematic claims processing functions, including complex
claims and inquiries and investigation, troubleshooting, and resolution of
complex issues. Understand each provider’s individual needs and contracts.

2. o Basic/Intermediate/advanced claims adjudication and review – including
Inpatient, Special Facility, COB, and any other claimtype as designated by
supervisor.
o Monitor claimbatches ensuring timely processing of claims.
o Investigate and apply contract benefits.
o Applied CCI edits (correct coding initiative edits)
o Sort and review miscellaneous problematic claims.
o Identify and report any irregularities or trends in claims processing.
o Address systemgenerated claims emails.
o Log all pertinent information into claims notes during the adjudication and
review of claims.
o Claimadjustments resulting from phone calls, corrected bills, internal
emails/requests, misc mail, COB, TPL and refund requests.
o Process corrected claims by creating copied claims, voided lines, punch credits,
etc.
o Process refund requests.
o Process claims utilizing referrals and pre authorizations.
o Provide internal and external customer service.
o Continuous HIPAA training.
o CIM (Claims Integration manager)
 SAIF Corporation, Salem Oregon – April 1996 to January 2014
o Medical Auditor II:
o Conducted medical and other bill audits in a fast paced production environment
according to established procedures and in accordance with regulations to
ensure appropriate payments are made for medical services.
o Reviewed automated audit results and documentation and made adjustments
when necessary in accordance with accepted conditions, policies, guidelines,
coding standards and regulations. Researched medical audit system issues and
communicated recommended actions to internal and external customers,
including claims adjusters, medical providers, and MCO’s. Explained pertinent
laws, rules and policies to internal and external customers, including claims
adjusters, medical providers and MCO’s and how the policies impacted audit
recommendations. Reported unusual billing patterns for follow up and referral
to the Fraud and Investigations Unit when applicable. Requested refunds from
providers when overpayments occurred. Adjusted worker reimbursement bills
when an overpayment occurred. Processed Prescription drug authorizations and
billings through pharmacy benefit on-line system, using knowledge of standard
pharmacy codes and company policies. Communicated with claims adjusters and
pharmacies regarding issues related to processing drug prescriptions.

3. o Audited medical and worker reimbursement bills (CMS-1500, UB92 forms, etc.)
per the OAR’s /Oregon Administrative Rules, Bulletins and Oregon Fee Schedule,
MCO (Managed Care Organization) and hospital cost charge discounts, etc.
Confidential and Third Party audits. Applied MCO guidelines. Corrected or added
CPT, ICD-9 and Hospital Procedure Codes, Hospital Revenue Codes, HCPCS,
Dental, Psych, PT/OT, Chiro, Surgery, Rehab, DME, medical supplies and NDC
codes per audit rules. Reviewed chart notes to ensure correct coding and level of
service applied, changed CPT code if needed. Monitored claimconditions.
Handled rebills and denial situations and applied EOB text as appropriate quoting
OAR’s and stating rules.
o Provided billing customer service and audit resource, in person and on phone, to
internal and external customers (Claims Adjusters, Nurse Consultants, Medical
Provider office, Doctor, Pharmacist, WCD (Workers Compensation Division),
DCBS (Department of Consumer and Business Services), other insurance
companies, etc.)
o Explained rules, regulations, policies, Oregon administrative Rules (OAR’s) and
bulletins to internal and external customers, in person and on the phone.
o Gathered/retrieved and used information from various computer systems.
o Data entry using keyboard and numeric 10-key.
o Handled daily pharmacy transactions through the Pharmacy Benefit Manager
OPDP/Medimpact/Wellpartner. Verified eligibility and coverage dates. Dealt
with Adjuster’s, injured workers and pharmacies to ensure prescriptions were
allowed/rejected appropriately and that brand sourcing applied correctly and
when appropriate. Made sure correct DEA numbers used. A lot of trouble
shooting and phone customer service with injured workers waiting in the
pharmacy. Many rush situations handled for various reasons. Ensured workers
received their medications/supplies/treatments in a timely manner.
o Provided Medical Auditor training when needed for new employees to learn the
many systems, policies and complex audit procedures.
o Provided help in our small floor mailroom and also the main company mailroom.
Opened and sorted incoming mail. Picked up and distributed mail to 11 floors in
two separate buildings. Prepared outgoing mail by running through envelope
adhesive and postage machines, ensuring correct postage applied.
o Continuous HIPAA training.
 BCBSO/HMO, Salem Oregon – March 1991 to June 1994
o Claims Analyst: Analyzed and audited medical bills applying OAR’s and Oregon
fee Schedule, MCO guidelines. HCFA, UB92, Pharmacy, Dental forms, etc.
Ensuring correct CPT, ICD-9, HCPCS, DME, Hospital revenue codes, etc. billed
appropriately. Changed office visit levels of service when appropriate. Provided
in person and phone customer service to internal and external customers. I also
helped out with referral/prior authorization specialist job duties.

4.  Fairview Training Center, Salem Oregon – March 1985 to May 1990
o Psych Aide/Medication Aide: Assisted clients with all daily living skills.
Transported to school, medical/dental appointments, shopping and outings.
Passed medications and applied treatments per MD and RN orders. Transcribed
orders. Reviewed and documented daily in both medical and personal charts.
Education/Licenses/Certifications
 VOCATIONAL CERTIFICATION/DEGREE IN CLAIMS ANALYST COURSE
o Chemeketa Community College; Salem Oregon January 1990
 Studied CPT and ICD-9 coding, Medical Terminology, human anatomy
& physiology
 OREGON CLAIMS EXAMINER CERTIFICATION
o SAIF Corporation; Salem Oregon – 1999 to present (continiously certified)
 MEDICATION AIDE CERTIFICATION
o Fairview Training Center - 1986
SKILLS AND EQUIPMENT EXPERIENCE:
 Computer - Word, Excel, Outlook, MARS (Medical Audit Review System), CARS (Claim
Audit Review System), HARS (Hospital Audit Review System), Sharepoint,
OPDP/MedImpact/Wellpartner pharmacy system, PBM (Pharmacy Benefit Management
System), CIM (Claims Integration Manager), EncoderPro, Halogen
 Keyboard
 Numeric 10-key
 Multi-line phone
 Fax/scanning machine
 Copy machine
 Micro fiche machine
 Mail sorting and postage machines
 Date stamp machine
 Dragon Speak technology
 Kronos
*References Available Upon Request