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Click here or scroll down to respond to this candidateCandidate's Name
Candidate's Name
PHONE NUMBER AVAILABLE (CELL)PHONE NUMBER AVAILABLE (CELL)St. Peters, MoEMAIL AVAILABLESUCCESSFUL HEALTHCARE PROFESSIONAL with diverse experience in healthcare, Quality Monitoring and Auditing, Credentialing, Recredentialing, Claims, Post Close, Hospitals and clinics, COB, Medicaid, and Medicare Patient follow up.Recognized for the use of creative approaches to achieve best outcomes at the client and organizational levels. Effective relationship builder with extensive experience including competency in: Command of medical insurance claimsconfiguration Proactive solution finder Detailed oriented Effective communicator Effective team member Claim Liaison Business analysis Documenting business process Business process, benefits, pricing, andcontracting Call Center Credentialing Commercial Credentialing Managing Employees/Volunteers Recruitment & Retention Customer Relations Corporate Training & Presentations Claims adjustments, post close Enrollment process & HealthcareProfessional Relations/PriorAuthorization Workers Compensation Providers reimbursementmethodologies Managed Care Patient Follow up/ Enrollment Post Close Quality AuditingSkill/SystemsEPIC certified, V-Look up, Proficient with Windows based programs and Microsoft Office (Excel, Word, Access, and Application). Care medic, Oracle, Citrix, URV Facets, Macess, PPO One, PPACA, VCC DESKTOP, Insight Suites, Cisco Jabber, SOP, UHC- IDRS, HRIS systems, Outlook, Amisys Advance, Pega, CenPas, CRM Prod, AWD, True Care, CMS, NCCI, CPT, 10-key calculator, and computers, Cactus Credentialing software CRM, RCAP, ICD-9, ICD-10 codes, Micro strategy Report, HCI, AR systems, Billing, Claims, Authorization, Medical Collection, Payment Posting, Workman Comp, Credentialing, Re-Credentialing, Enrollment processor, Ability to perform basic math functions and reason logically. Working knowledge of ICD-9, CPT, HCPCs, revenue codes, and medical terminology, Experience with Home state Health (Medicaid), Ambetter (Market Place), Allwell (Medicare) and, Cenpatico Behavioral health claims, Care Connect,ICBM (I3), PROFESSIONAL EXPERIENCECandidate's Name
Centene Corporation (Home State Health), Chesterfield, MO 07/2022 to Present Centene Corp is a health care organization that operates different accounts for all states Medicaid and Medicare facilities. Contact Center Quality Specialist IPosition Purpose: Conduct quality monitoring and auditing of all call agents at assigned call centers and plans. Perform quality check of calls received for new call centers and existing plans Identify and monitor trends and quality risks Deliver quality performance feedback to call agents and management Actively participate in quality calibration sessions with quality team members and call center management Assist with identifying and providing training in response to trends and patterns identified Assist with developing policies, procedures, and performance standards for call centers Assist with servicing Members and Providers as needed Centene Corporation (Home State Health), Chesterfield, MO 11/18 to 07/2022 Centene Corp is a health care organization that operates different accounts for all states Medicaid and Medicare facilities.Claims Research Specialist / Grievance & Appeals Coordinator Position Purpose: Perform duties to act as a liaison between provider relations, provider services, and the health plan and corporate to investigate and resolve claims inquiries. Provide support and direction for the daily operations of the appeals function Provide consultation for problem resolution for appeals staff and monitor teamwork output to ensure compliance with internal and NCQA standards. Identify training, process improvement and resource needs to maximize team performance and recommend action plans to management Review denial and appeal letters as needed to ensure appropriate content and message Prepare for state/health plan audits, response to complaints and request for state fair hearing documentation. Prepare monthly reports, logs, and other health plan or state contractual requirements Review and monitor team workload and output to ensure optimum efficiency and accuracy serve as the point of contact for issues that arise from members, providers and internal team Train and educate new and existing team on processes, policies and procedures, and contract or market requirements Receive and respond to internal and external claims related issues. Initiate entry or change of provider related database information. Complete claims related research projects. Assist with responsibilities related to data integrity of provider claims processing system. Investigate and communicate reimbursement and benefit changes. Educate provider relations, provider services and claims liaisons regarding policies and procedures related to referrals and claims submission. Assist providers with resolving issues with claims submission and payment accuracy. Attend state meetings with regards to fee schedule and benefit changes. Assist with provider complaints & resolutions regarding claims issues and Candidate's Name
process claims adjustments. Review all Medicaid Bulletins for changes and updates and submit change requests (CRs) to update payment system. Support Liaison 11/18/2018 to 09/15/2019This position responds via telephone to issues from internal and external customers, identify and solve issues, send more complex issues to other support function within Claims Support, and follow issues through completion.. Respond to telephone inquiries and initiate steps to assist callers,. Research claim payment issues to identify root cause and trends to reduce incorrect payments. Thoroughly document information, activities, and changes in database. Develop and maintain positive customer relations with internal and external customers and coordinate with various functions within the company to ensure problems, requests, and question are resolved timely,. Receive and place follow up telephone calls/emails to answer internal and external customer questions that are routine in nature,. Relay complex claims support issues to other functions within the Client Support Services area.Centene Corporation, Creve Coeur, MO (Aerotek)02/2018- 11/2018Centene Corp is a health care organization that operates different accounts for all states Medicaid and Medicare facilities.Lead Advance Claims AnalysisThis position is primarily responsible for maximizing my team leading experience in a challenging environment, guiding by example, and utilizing vast experience in directing a team towards its objective within the deadlines and thus achieving the corporate goals. Trained in processing claims for the state of Texas, Participated in the new plan implantation for other states, where in addition to basics pricing, and advance analyst training, I have been trained in the COB process as well and have been approved for mentoring in COB and claims training classes. I have been tasked with submitting work process updates and assist with researching high dollar complex claims. Conduct training needs analyses to determine specific training needs for department staff. Identify, select, and develop appropriate training programs, including the selection or design of appropriate training aids. Assist in auditing work performed by staff and present findings and recommendations for areas of improvement to management. I would have to respond directly to the provider with final resolution of the issues, and the root cause of the issue. Centene Corporation, Chesterfield, MO 01/2016 01/ 2017 Centene Corp is a health care organization that operates different accounts for all states Medicaid and Medicare facilities.Candidate's Name
Prepaid Compliance AnalysisThis position is primarily responsible for recruitment accepting and rejecting coding recommendation according to provider information. Compare provider billing and code auditing recommendation based on regulatory coding logic and state, CMS, and NCCI guidelines and rules (Current Procedural Terminology) Research, investigate, and resolve escalated inquiries and issues related to code editing adjudication for all health plans. Conducted candidate sourcing utilizing internet research, cold calling, and candidate data base research. Provide research necessary to address issues and concerns that potentially prevent provider abrasion and explain to providers why claims have been denied, knowledge of managed care information in claims payment system, and commercial insurance in benefits configuration Train and audit team members on system/ checking processing for all health planes. Built strong and lasting relationships while training for Supervisor role and fellowship directors. United Healthcare, Maryland Heights, MO 10/2013 01/2016 United Healthcare is a managed health care company based in Minnetonka, Minnesota. It is the sixth in the United States on the Fortune 500Claims Adjuster-Resolutions SpecialistThe Claims adjuster is responsible for all aspects of adjusting complex medical and hospital claims train other staff on process Research, analyze and recommend external training programs, and credentialing/re-credentialing for providers. Review medical documentation for accuracy, and medical necessity. Submit for prior authorization with all required documentation to appropriate funding source Maintain consistent follow up on status of all prior authorization requests Review authorization from payer to determine approved and denied items. Calculate estimated copay based on current insurance benefits. Communicate with Supervisor regarding issues and changes with Payer respond to all internal and external customer in a timely &professional manner. Implemented quality audits review for other co-workers. Successful state annual reviews with complimentary marks. Conducted leadership and corporate training. Assist in auditing work performed by staff and present findings and recommendations for areas of improvement to management Identify, select, and develop appropriate training programs, including the selection or design of appropriate training aids Processes for all medical health providers who provide patient care at select rehabilitation. I had to ensure providers were credentialed, appointed, and privileged with health plans, hospitals, and patient care facilities, made sure of data base up to date, ensure timely renewal of certifications and licenses. Conifer Health Solutions, St. Ann, MO 05/ 2013 10/ 2013 Conifer Health Solutions is a Managed service to health systems, their health plans, and managed populations for more than 30 years.Candidate's Name
Claims AdjusterThis position is responsible for Commercial Credentialing insurance billing, researching accounts, patient scheduling for providers to update Medicaid and Medicare. Reviewed and approved individual members service care plans. Processes for all medical health providers who provide patient care at select rehabilitation. I had to ensure providers were credentialed, appointed, and privileged with health plans, hospitals, and patient care facilities, made sure of data base up to date, ensure timely renewal of certifications and licenses. Reviewing the client email box for Incoming Emails, assists with follow-up activities related to patient, guarantor and insurance company Ensured effective training and coaching for staff. Educate providers regarding policies and procedures related to referrals, claims submission, credentialing documentation, web site education, Electronic Health Records, Health Information Exchange, and Electronic Data Interface, knowledge of managed care information in claims payment system, and commercial insurance in benefits configuration. Track all claims as well as research information found about the claim, reviewed contracts, comparing contract revision, populate tracking term, verify correct processes were followed for the health plan. Prepares and distributes pertinent reports to Manager and Supervisor. Outsourcer Group, Earth City, MO 06/2012 05/ 2013 The Outsource Group is an accounts receivable management company, assists hospital, physicians, and dentists in the collection of traditional past due accounts from both patients and commercial payers as well as claims.Claims Adjuster for Workers Compensation/Medical Collection The Claims adjuster would adjust past due claims. Maintain records of training activities and employee progress Receive and prepare workers comp claims, enter claim data in the system, set up claims and file. Insurance billing, researching accounts in client systems including payments, inbound, and outbound calls to clients. Reviewing the client email box for incoming emails. Reviewing Claims in a timely manner, and attentive to detail Collect on past due claims accounts while gathering and analyzing documentation before I sent account to the legal depart, knowledge of managed care information in claims payment system, and commercial insurance in benefits configuration Provided community outreach to referral sources that included clinicians, social workers, healthcare professionals, county and government agencies, civic and community agencies trying to find additional resources for the patient, and provider. Magellan Health Care, Maryland Heights, MO 06/2005 05/2009 Magellan Health is an American for-profit managed health care company, focused on behavioral healthcare. It ranked 652 on the Fortune 1000. Prior Authorization/ Credentialing Specialist/Claims Analyst The Claim Specialist would provide enrollment and primary source verification. I would assist with enrollment in all insurance network like Medicare, Medicaid, and Commercial insurance for any organization. Prior Authorization I would talk with the insurance company to see if and authorization was need and to see if it would be covered or a denied authorization. Claims Candidate's Name
Analyst I would have to research and determine status of medical claim and review charges in system and use payment or denial codes, clarify health insurance coverage for coordination of benefits to process claims, and maintain records. Review structured clinical data matching it against specified medical term and diagnoses or procedure codes (without the need for interpretation) and follow established procedures for authorizing request or referring request for further review. Answer calls from physician office, hospital and patients using exemplary customer service skills, knowledge of managed care information in claims payment system, and commercial insurance in benefits configuration. Processes for all medical health providers who provide patient care at select rehabilitation. I had to ensure providers were credentialed, appointed, and privileged with health plans, hospitals, and patient care facilities, made sure of data base up to date, ensure timely renewal of certifications and licenses. Accurately enter required information (non-clinical and structured clinical data) into computer database.EDUCATIONCurrently attending Webster University, to obtain my BS/BM degree West County Technical High School, Chesterfield, MO |
