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Click here or scroll down to respond to this candidateCandidate's Name
Professional Summary:The candidate is a Spanish bilingual and has been in the healthcare industry specifically in processing medical claims for 17 years. Her tasks include adjusting claims, checking eligibility status, resolving payment discrepancies, and navigating through different systems to research policies and guidelines. She also has a reliable internet connection to work at home.Skills:Claims Processing/AdjustmentPost-Payment ClaimsBillingCollectionMedicaidMedicareOutbound Phone CallsCMSSpanishProfessional Experience:Technical Claim Specialist Mar 2016 Apr 2022Zenith American Solutions, Tampa, FLTested a new line of business and transferred the patients records to the new system.Processed claims and adjustments.Called the providers to get updated W9s and submitted them to be entered into the system.Verified and updated the members eligibility status.Billing Specialist Sep 2015 Mar 2016Surgery Partners, Tampa, FLCalled the insurance company to follow up on the payment.Sent out collection letters and entered corrected diagnosis codes.Network Specialist Mar 2014 Sep 2015Integral Quality Care, Tampa, FLWorked with the Network Recruiters to obtain the required missing information necessary to complete the contracting process.Completed provider configuration forms for all additions, termination, and demographic changes to the provider network for participating and non-participating providers including delegated groups.Completed State Reports.Wrote up Single Case Agreements and submitted them to the provider for review and signature.Provider Resolutions Specialist Apr 2012 - Dec 2013WellCare Health Plans, Inc., Tampa, FLReviewed and responded to written provider disputes, clearly and articulately outlined the payment discrepancy to the provider.Thoroughly researches post-payment claims and takes appropriate action to resolve identified issues within turnaround time requirements and quality standards.Navigated CMS and State-specific websites, as well as AMA guidelines, and compared to current payment policy configuration to resolve the providers payment discrepancy.Reviewed medical records to ensure coding is consistent with the services billed and compared against the clinical coding guidelines to decide if a claim adjustment is necessary.Claims Specialist Oct 2010 Apr 2012Beacon Health Solutions, Tampa, FLReviewed, evaluated, and processed claims and made recommendations for resolution.Processed JMH and Atlantis Commercial claim that is pending for various hold reasons to assist in the final determination on claim disposition.Processed adjustments related to projects or correspondence.Claim Examiner Feb 2008 Sep 2010Citrus Health Care, Tampa, FLAccurately interpreted, understood, and applied Medicaid and Medicare contracts.Prepared and submitted daily production reports.Worked with other departments to resolve issues.Periodically ran system queries as necessary.Prepared correspondence and maintained phone logs & contact logs, as well as projected resolution for all markets.Claim Specialist Dec 2006 Feb 2008AmeriGroup Corporation, Tampa, FLAudited and processed all advanced-level claim transactions.Accurately applied Medicaid and Medicare contracts.Prepared and submitted daily production reports.Periodically ran system queries as necessary.Claim Specialist Oct 2001 Jul 2006National Benefit Fund, New York, NYManually entered all HCFA 1500 forms into the system to process or deny.Reviewed and made any necessary claim adjustments or requested further information or medical records.Education:Some College 2012American Public University, West VirginiaGEDPark West High School, New York 1982 1985 |
