Linda Dunlap

Responsible for proper adjudication of claims submitted to the PreShield platform, reviewing flagged claims before proceeding to post-pay status. Duties include monitoring claims for timeliness, answering inquiries, and maintaining systems access. Developed a job aid for the Clinical Analyst II role.

Responsible for proper adjudication of various claims for Medical Necessity in Post-pay review. Ensured compliance with medical guidelines and policies.

Responsible for reviewing post-pay claims for possible fraudulent activity. Conducted thorough investigations to identify discrepancies.

Responsible for the medical review of Medicare Part B claims in post-pay status, including Durable Medical Equipment (DME) and Clinical Labs. Researched and reviewed medical policies to ensure proper claim adjudication.

Responsible for post-audit review of high-cost implants, validating billed charges from facilities using systems like CCB, NASCO, CITRIX, and FEP. Reviewed operative notes, manufacturer invoices, and implant records to determine correct payment. Transitioned to Clinical DRG Readmissions, identifying similar diagnoses and related complications per contract language to determine readmission status.

Responsible for proper adjudication of Medicare B claims in the prepayment area using current Medicare policies to determine medical necessity. Duties included peer training for new hires and communicating new Broadcast Messages detailing CMS changes. Performed duties in the Pricing/Reimbursement area, including pricing for Claims, Appeals, and high-level appeals QIC. Assumed a new role in Targete

Completed a Bachelor of Science in Nursing program. Focused on core nursing principles, patient care, and clinical practices.

Pursued a Bachelor of Science in Medical Technology. Gained expertise in laboratory procedures, diagnostic testing, and medical instrumentation.