To obtain employment in a medical office and/or health insurance setting where I can maximize my Insurance Verification, Administrative Assistant, organizational and communication skills and make a positive contribution to the organization.
Confidential, Long Beach, CA
PIM Coordinator - Provider Data Management Analyst
- Responsible for gathering, coordinating, and processing of data from the provider network for entry into the Provider Information Management System (QNXT)
- Ensures accurate provider contracts are correctly configured, affiliated and applied with appropriate demographical information.
- Accurately interprets claims data and enter into the system in such a way that all data is correct and claims adjudication is optimized
- Determine claims processing errors in relation to provider system data and correct or route accordingly to appropriate department for corrections.
- Train current staff and new hires as necessary.
- Audit loaded provider records for quality and financial accuracy and provide documented feedback.
Confidential, Angeles, CA
Confidential - Krystal Mays
- Responsible for contacting healthcare provider offices to schedule field medical coders, medical record technicians and other resources for various medical chart reviews.
- Assisted in the full range of provider outreach and service interactions within Confidential, including end-to-end provider scheduling and call quality
- Support incoming calls from Confidential medical coders, medical record technicians, and provider offices.
- Responsible for preparing, sending, and receiving correspondence externally and internally
- Coordinates travel requirements for Confidential Field (travel) medical coders and medical records technicians.
- Maintains effective and collaborative internal relationships with all key functional areas.
- Daily reporting of project productivity.
- Reconciles scheduling data.
- Daily reporting of project productivity and performs special assignments as required
Quality Assurance Administrative Assistant
- Provided administrative support to the Quality Assurance Managers and Vice President of Education and Consulting Services.
- Assisted Quality Assurance team with various tasks regarding quality reports.
- Created tracking and reporting processes for team.
Confidential - Sergio Carmona
- Primarily responsible for assisting and providing instruction to low income qualified individuals enrolling into state funded assistant programs.
- Responsible for continuous contact with member during their recertification process to see that renewal/recertification process is completed.
- Assists participants with all questions regarding completing application and recertification process.
- Evaluate and determine eligibility for state programs and actively research and stay informed on all state regulations and laws in regards to recertification forms and processes.
- Acting as a liaison between the state to ensure member continuation in state affiliated programs.
Insurance Verification Specialist
- Responsible for verifying, obtaining and logging patient benefits and prior authorizations.
- Coordinating with insurance plan and doctors office to obtain prior authorization.
- Verifies primary and secondary insurance coverage for patients; makes written and/or verbal inquiries to payers to verify insurance status and prior authorization status.
- Obtains and facilitates all letter of medical necessity (LMN) necessary
- Verifies and logs patient’s co-pay with Payer.
- Contacts patients, physicians and other health care providers to obtain necessary information to complete a thorough insurance investigation. This includes patient eligibility, how drug is covered, co-pay, deductible, and OOP max. Benefits and prior authorization requirements.
- Identify situations in which a patient may need financial assistance and reach out to patient to help them obtain assistance.
- Coordinate with companies offering financial assistance, patient and physician to obtain assistance in an expedited manner. (ex: Chronic Disease Fund, LLS)
- Manage/process all insurance changes related to current patients enrolled in the BioScrip program.
- Logs all calls made/received into the system.
STNA and Assistant Activities Director
- Change, feed and bathe residents; attending to other personal and grooming needs such as combing hair, trimming nails, brushing teeth, passing bed-pans and helping residents to the bathroom
- Turn and position bed patients according to turning schedules.
- Assisting patients, physicians and pharmacies in: drug coverage pre-certification requirements and status claims concerns
- rder and shipment concerns
- Prescription Status
- Identifying situations that require a pharmacist.
- Understanding emotions through caller tone and words and correctly de-escalating situations and applying proper resolution.
- Enrolled new members into Medicare Prescription Drug Plan
- Understanding Medicare Program, providing education to callers regarding Medicare prescription drug plans and processing enrollments into plans while following proper Medicare guidelines.
Customer Service Consultant
- Handles telephone and written correspondence from members and physicians.
- Explains customer/member specific plan of health and pharmacy benefits along with member's responsibilities in accordance with contracted arrangement
- Copay/ Coinsurance
- Pre-certification requirements
- Referral status
- Claim Status
- Coordination of Benefits
- Confirmed for patients and physicians status and requirements of pre-certification approval.
- Documents and tracks all member contacts, events, and outcomes via appropriate systems.
- Reviews claims cost payments in order to respond to all requests for reconsiderations or appeal.
- Assisted members in determining correct coordination of benefit between primary and secondary insurances. Accessed information from a variety of systems and references including contracting and network system.
- Enrolled new members into health and prescription plans.
- Processed Health Insurance Claims
- Skilled in ICD-9 and CPT coding, medical terminology, Medicare practices, COB determination
- Processing inbound electronic faxes
- Contacting providers to confirm prescriptions.
- Inbound call center environment assisting customers with contact lens orders, returns shipping inquiries billing information.
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