Maljhon Gumera

Detail-oriented Healthcare Claims Analyst with nearly three years of experience processing vendor- and non-vendor-delegated claims under the BCBS Five Pearl Plan covering Illinois, Texas, Montana, New Mexico, and Oklahoma. Skilled in resolving membership and group data discrepancies, reviewing medical records for authorizations, and ensuring compliance with payer guidelines and HIPAA regulations. Proficient in industry-standard systems and tools to support efficient, accurate claims workflows while collaborating effectively with cross-functional teams to deliver timely, high-quality results.

Job Title: Transaction Processing Associate
 

Key Responsibilities:

Process paper image claims and scanned medical records for accurate claims adjudication and clinical review.

Handle vendor and non-vendor-delegated claims under the BCBS Illinois Five Pearl Plan, resolving data discrepancies.

Review medical documents for prior authorization and prepare records for routing.

Use tools such as Bluechip Emulators, Bluesquared, Bluestar, COB Tool, and Carelon Portal.

Ensure HIPAA compliance and maintain data integrity.

Collaborate with clinical and ops teams to resolve claim issues and improve workflows.

Support process improvements to boost accuracy and efficiency.

Special Assignment – AIM Manual Method Handling:

Trained to manage AIM Manual Method for specialized authorizations.

Uploaded records to Carelon Portal and verified documentation for medical necessity.

Worked with authorization teams to resolve issues and meet quality standards.

Maintained HIPAA compliance across all processes.

Encoding and Mapping Specialist
Encoded land titles and ownership data into the Land Registration System database.

Verified and corrected parcel boundaries using technical plans and cadastral surveys.

Applied geospatial adjustments for accurate land mapping and alignment.

Collaborated with surveyors and GIS teams to resolve data discrepancies.

Ensured data integrity and compliance with land registration standards.

• ICCT COLLEGES FOUNDATION, INC.
• Bachelor of Science in Information Technology
• Completed in 2017