TECHNICAL SKILLS:

• Medical Terminology
• Help Desk
• VoIP
• Remit Advice
• Accounts Receivable
• Conflict resolution
• MySQL
• CPT, ICD 9
• Telephone Application
• Quality Assurance
• Outbound/Inbound calls
• AS400
• Outlook/MS Exchange
• PC & MS Office proficient
• Payment Posting
• PeopleSoft
• Virtual - based customer service
• Third-party Service
• Technical Support
• Call Center
• Customer Operations
• Problem Solving Skills
• 45wpm
• Billing/Collections

PROFESSIONAL EXPERIENCE:

Confidential

Customer Service Specialist

Responsibilities:

• Empathized with and prioritized every customer’s needs with respect and patience while showing ownership and upholding company values.
• Answered and managed incoming and outgoing calls while recording accurate messages
• Fluent in Windows Operating System and Microsoft Outlook Accustomed to using multiple browsers, multiple tabs and window navigation, and instant message tools.
• Resolved product or service problems by clarifying the customer's complaint; determining the cause of the problem; selecting and explaining the best solution to solve the problem; expediting correction or adjustment; following up to ensure resolution
• Approached problems logically and with good judgment to ensure the appropriate customer outcome.
• Documented customer account activities thoroughly and concisely.
• Gained experience working with customer from different ethnicities.
• Understood the importance of managing sensitive member information with integrity

Claims Auditor

Responsibilities:

• Reviewed claims and coded treatment procedures using Common Procedure Terminology (CPT) codes
• Reprocessed underpayments, appeals denials and turns them into payments, ensures accurate reimbursement on all claims
• Audited accounts for proper payments, coding, balances, adjustments, etc. using appropriate reports andwork queues to do so.
• Translated dental procedures into codes that can be translated by payers, other medical coders, and other medical facilities
• Complied with Federal and State billing requirements. Also complies with Health Information Portability and Accountability Act (HIPAA) and Electronic Data Interface (EDI) transaction formats.
• Medical billing and collections

Claims Adjuster

Responsibilities:

• Made calls and answered customer questions, issues and complaints
• Completed and submitted Medicare and Medicaid hospital billing claims to primary and secondary insurance claims
• Submitted medical appeals to the insurance providers
• Applied provider payments on accounts, applied contractual managed care reimbursement rates
• Responsibilities included posting patients’ accounts, initiating patient’s insurance claims and follow-up and unpaid and denied claims with the facets workflow system.
• Review claims for necessity, limitations, and exclusions base on claim policies and procedures
• Worked with debtors to establish patient financial services to ensure accurate and timely billing and collections from third party payors and patients

Claims Auditor

Responsibilities:

• Processed insurance claims, and entered information needed for payment.
• Exceeded requirements for daily production needed.
• Verified and analyze procedure codes used on claims to valid and process claims within the company’s guidelines.
• Reviewed of insurance carrier processes and procedures and claim handling in accordance with the National Association of Insurance Commissioners (NAIC)
• Research and process claims according the processing guidelines and benefits
• Knowledge and use of ICD-9, ICD-10 and CPT coding

Customer Service Agent

Responsibilities:

• Provided education to pharmacist for over 40 products and services offered through RelayHealth. Provided superior customer service by resolving customer issues and communicating escalated issues to the appropriate departments.
• Utilized high proficiency with both industry and proprietary software applications to resolve technical issues.
• Guaranteeing HIPAA compliance by securing enrollment and controlled access to state government regulated reporting programs.
• Provided training to the pharmacist for over 40 products and services offered through Relay Health. Contributed to team success by providing after-hours customer service work from home.
• Contributed to the success with departmental SLA's by efficient utilization of the SalesForce.

Collection Specialist

Responsibilities:

• Managed and worked batch error reports, which allowed the correction of payments and reimbursements for the amounts to be correctly distributed to the payers and or patients.
• Organized and managed guidelines on spreadsheets used by different department personnel for verifying steps and procedure .
• Performed various duties relating to priority work requested from management and co-workers in order to complete task in a timely manner.
• Successfully worked with external auditors to achieve favorable results on audit accounts for quarterly reviews
• Maintained and submitted all annual charitable write-offs to the State for company compliance.
• Provided account maintenance for patient’s accounts to identify actions taken on the Charity database. Delivered assistance to internal and external customers inquiring about medical statement.
• Handled patient questions pertaining to their current or past due account balance.
• Managed primary, secondary, VA and worker’s comp reimbursements claims for patient’s insurance companies. Resolved coding and billing problems from EOBs and corrected errors in a timely manner.
• Retrieved all patient financial and demographic records in order to close-out an account within designated time frames.