PROFESSIONAL EXPERIENCE

Confidential, Irving, TX

PIM Analyst

Responsibilities:

• Provide Superior Customer Service to providers
• Answer and/or return all incoming calls within 4 hours to providers and customer service inquiries
• Provide by mail, fax or email copies of EOR’s to provider when necessary
• Ensure proper follow - up and customer communication when appropriate
• Prescreen claims for the purpose of applying preauthorization of rules according to ODG guidelines
• Prepare Claims for entry, applying the proper denial code for no preauthorization
• PLN, PEER, RME, DDE, IRO and other report entry into system annotation history for all client claims

Confidential - Dallas, TX

Claims Adjuster Assistant (Contract)

Responsibilities:

• Ability to use adjuster knowledge by assisting and providing clerical and administrative support to a group of Worker’s Compensation Case Managers
• Accurately set up new requests for medical services from providers in order to treat the injured employee via EDI, utilizing knowledge of medical and insurance terminology, ICD-9, and CPT 4 codes
• Managed incoming calls from medical providers, legal staff, and claimants in reference to the injured employee

Confidential, Carrollton, TX

Support Team Lead / Medical Prescreen

Responsibilities:

• Managed prescreening for the purpose of applying preauthorization of rules according to ODG guidelines
• Managed the SFI (scan file index) functions to ensure that the appropriate Quality Assurance (QA) was being provided
• Established and maintained relationships with all clerical staff to ensure knowledge of their accounts, process and workflows from all levels
• Assisted with annotations, interface of medical claims with Medical Bill Review
• Managed employees and worked with management to proactively evaluate staffing needs
• Oversight of performance reviews, training and relationship building

Confidential -Dallas, TX

Customer Service/Collections Specialist

Responsibilities:

• Re-priced and reported savings on claims for contracted insurance participating with ACS PPO networks
• Processed payments from insurance to send to participating providers
• Quality assurance on claims to ensure they were sent out clean also on payments to ensure providers were paid correctly
• Answered incoming calls from providers that wanted to check status of claims that were re-priced and billed on their behalf

Confidential

Medical Claims Reviewer

Responsibilities:

• Performed data entry of provider generated HCFA 1500 and UB 92 hospital bills
• Audited company generated Explanation of Benefits for accuracy of ICD-9 CPT 4 and HCPCS codes
• Made contact with providers for missing billing information per company protocol
• Performed special assignments related to claims processing/bill review as directed by supervisor or team lead

Confidential - Coppell, TX

Medical Claims Reviewer

Responsibilities:

• Performed data entry of provider generated HCFA 1500 and UB 92 hospital bills4
• Audited company generated Explanation of Benefits for accuracy of ICD 9, CPT 4 and HCPCS codes
• Made contact with providers for missing information per company protocol
• Performed data entry duties of claims form from KFI/OCR (key from image/optical critical repair) data base
• Performed scan room duties of placing provider claims forms into KFI/OCR database by way of Kodak scan equipment
• Performed mail room duties of company generated information to providers and clients notifying of status of submitted claims
• Performed back up duties of processing incoming claims for the purpose of preparing claims to be coded and data entered into database
• Performed back up customer service duties receiving and making calls to providers and clients

Confidential -Irving, TX

Customer Service Rep / Medical Claims Analyst

Responsibilities:

• Answered incoming calls from plan participants regarding pre-authorization of medical procedures and admissions as outlined by healthcare carrier
• Made outbound calls to healthcare facilities verifying dates of discharge
• When guided through by company software and criteria, authorized office visits and surgical procedures for plan participants
• Audited incoming provider claims with the purpose to ensure prior authorization was given from carrier to provider for specific procedures and medical equipment according to Texas Workers Compensation rule 134.600
• Prepared incoming claims for data entry staff by batching and labeling claims
• Performed back up data entry duties of overflow claims as directed by supervisor or team lead utilizing the Texas Workers Compensation fee schedule

Confidential - Dallas, TX

Medical Records Clerk

Responsibilities:

• Responsible for the entry of ICD 9, CPT 4, and HCPCS codes into the hospital data base for the purpose of generating patient bills
• Prepared Physician generated Attestations for Medicare, Medicaid and other DRG related insurance groups for the purpose of review by physicians
• Performed receptionist duties directing phones calls and visitors to proper departments
• Performed file room duties of charts in terminal digit order to file in permanent file location
• Performed back up release of information duties as evening shift receptionist