SUMMARY OF QUALIFICATIONS
- Highly Qualified in Resolving issues Requiring Emphasis on Customer/Client Satisfaction
- Skilled in Representing the Department in Business Leadership Groups
- Proficient in Reviewing Medical Records Reviewed and Coded by the Coding Vendor
- Proficient with Research and Documentation of Workflows, Policies and Procedures and other Materials
- Proficient in Collecting and Analyzing Data to Formulate Recommendations and Solutions based on Audit Results
- Strong Analytical Skills to Analyze Complex Situations and Formulate Decisions
- Skilled with Large Work Volume, Tight Deadlines and Frequently Shifting Priorities
- Talented in Developing Relationships with key Referral Sources within the Healthcare Community
- Effective Collaboration with Management to Determine needs and Discuss Progression Strategies
- Proficient in MS Office, Outlook, Macess, Facets and Citrix
Confidential, Tampa, FL
Medical Claims Analyst
- Coordination of benefits experience using CMS COB guidelines determined primacy and processed on more than one platform.
- Reviewed, analyzed and processed claims/policies related to events to determine extent of company's liability and entitlement.
- Investigated, followed up and facilitated the resolution of claims issues, including incorrectly paid claims, by working with multiple operational areas and health plans and analyzing the systems and processes involved in member enrollment: provider information management, benefits configuration and/or claims processing.
- Analyzed problems and provided information/solutions.
- • Applied benefit contracts, pricing, processing, policies, procedures, gov't regulations, coordination of benefits, & healthcare terminology.
- Processed claims and products, including the grievance and/or re - consideration process.
- Billed proper CPT codes, research and analyze claims issues.
Confidential, Virginia Beach, VA
Front Desk Claims Coordinator
- Develops and maintains positive customer relations and coordinates with various functions within
- Input patient demographics, financial information and health insurance information into The Misys System.
- Verified patient health insurance via online or telephone.
- Collected patient’s co-pay, deductible and health care insurance information.
- Posted deductibles, co-pays, and receipts as reflected on the explanation of benefits from the insurance.
- Ensured the accuracy and completeness of diagnosis codes before submission to claims department.
- Communicated with collections department to resolve billing issues in a timely manner.
- Obtained necessary consents (HIPPA), identification and financial documents required for medical legal, medical evaluations and second options.
- Ensured the clinical and financial screening criteria had been met prior to office visit.
Confidential Portsmouth, VA
Human Resource Front Desk Coordinator
- Maintained contacts and partnerships in the community
- Provided excellent client care at all times and greet clients upon arrival, and notify appropriate staff members
- Verified client application for up to date and accurate information
- Answered and transferred multi-line telephone in a courteous and timely manner
- Confirmed appointments and followed-up with clients regarding missing application information
- Organized and maintained file system including filing of correspondence and other HR records
Confidential, Chesapeake, VA
Claims Agent Assistant
- Input PIP First Notice of Loss new claims information
- Utilized the claims search mechanisms to process and review existing claims
- Electronically attached claim documents to the claim files
- Created claim folders for hard-copy claim files
- Filed, photo copied, mail scanned and index, faxed, contacted brokers and insured's regarding "claim contacts".
- Managed the desks of Claim Examiners.
- Handled administrative and technical support to the Claim Examiners, printed and mailed checks; other administrative functions.
Confidential, Boynton Beach, FL
Office Manager Sales/Marketing
- Analyzed competitive product offerings in terms of features and benefits as well as price points.
- Maintained recruiting contacts and partners in the community
- Review product pricing and gross margin goals for existing products annually and establish new product pricing.
- Trained and assigned to perform the Customer Care Liaison duties between owner and client.
- Provided multi-tasking and organize within the office and in the field.
- Assisted in implementing the day-to-day functions of the accounting department.
- Worked with Intake Department to ensure accurate information is obtained
- Prepared and Processed month end billing reports for accurate billing.
Confidential, Portsmouth, VA
Home Care Manager
- Won "Service Excellence Award" for instrumental role in driving record-high customer service satisfaction.
- Trained CSRs and contributed to significant improvements in customer satisfaction.
- Communicated successfully with intake department regarding specimens, weights, and vital signs of patient.
- Served on special taskforce charged with turning around under-performing representatives.
- Introduced training programs that enhanced employee performance and helped build a motivated workforce.
Confidential, Delray Beach, FL
Program Relations Coordinator
- Recruited, mentored, and supervised youth participating in the Summer Program.
- Conduct pre-admission screenings to verify that students meet admission criteria.
- Implemented and scheduled education al programs for a youth audience.
- Coordinated and facilitated all activities including transportation, facilities, and participation.
- Recorded statistical measures of public participation and customer service satisfaction within the program.
- Compiled photographic documentations, prepared final evaluations and reports of the program at its completion.
Confidential Chesapeake, VA
Medical Claims Lead Representative (Appeals/Complaints)
- Completed accounts that required insurance appeals and followed up accordingly.
- Accurately prepared and submitted claims to third party commercial carriers and intermediaries according to facility, state, federal, and payer guidelines.
- Provided exceptional customer service (EOB’s) to Managed Care patients.
- Researched/Explained benefits and collaborated with the care advocacy department during the grievance process.
- Reviewed and processed healthcare appeals/complaints from members with denied claims.
- Logged and tracked progress of appeals/complaints turnaround time.
- Logged patient demographics’ and Medicare, Medicaid or Third Party Insurance information.
- Provided exceptional customer service to patients within a busy automatic inbound call center.
- Liaison for field staff, supervisors, and referrals department regarding verbal order and patients' comments.
- Ensured timely communication with warehouse on medical equipment orders for prompt delivery.
- Recorded monthly balancing of accounts involving monetary transactions and reported discrepancies.
- Completed monthly billing and follow up on all Home Care/Home Medical and Respiratory equipment.