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Click here or scroll down to respond to this candidateCandidate's Name
EMAIL AVAILABLE PHONE NUMBER AVAILABLE Fort Worth, TXSUMMARYSeasoned professional with 13 years of experience in claims management and systems configuration, actively seeking a Configuration Specialist II role. Expert in remote team leadership, engaging in contract negotiations, and ensuring data integrity. Proven track record in streamlining claims processes and maintaining compliance standards. WORK EXPERIENCEAlivi Miami, FLSystems Configuration Manager Nov 2022 - Nov 2023 Manage comprehensive data integrity for provider setups and ensure contracts are accurately implemented and tested within the claims system, adhering to relevant specifications and compliance standards. Develop and maintain workflows, policies, and procedures to support efficient client implementations, conversions, and system updates while providing mentorship on complex contract configurations. Conduct thorough reviews of contract language and engage in negotiations to optimize reimbursement terms, mitigate risks, and streamline claims administration processes. Oversee departmental staff, providing guidance and performance evaluations, while ensuring production and quality goals are met and maintaining strong interdepartmental relationships to facilitate effective claims processing.Integrated Home Care Services Miramar, FLClaims / Configuration Supervisor Nov 2018 - Nov 2022 Managed a team of professionals, overseeing recruitment, training, and performance evaluations, while ensuring adherence to departmental objectives and resolving personnel issues. Coordinated with internal departments and experts to troubleshoot and resolve complex claims issues, improving overall team efficiency and problem-solving effectiveness. Provided mentorship and developmental support to staff, enhancing team performance through individual coaching and collective training sessions. Established and maintained productive workflows with operational departments, optimizing claims processing and fostering interdepartmental cooperation. Conducted regular reviews of departmental performance metrics, ensuring compliance with Service Level Agreements and maintaining high-quality standards in claims management. Claims Team Lead Provided expert guidance on Medicare/Medicaid compliance, resulting in the accurate resolution of claims issues and adherence to payment policies, while also leading the training and re-training efforts to address claims denials and processing errors. Managed a team of 29, overseeing daily operations, including the resolution of escalated calls, maintenance of production reports, and ensuring the accuracy and completeness of claims batches prior to closure. Enhanced provider relationships and operational efficiency by analyzing billing trends, addressing complex claims issues, and implementing process improvements to optimize claims flow and departmental coverage. Claims Pricing Analyst Managed accurate entry and maintenance of provider contracts and fee schedules, ensuring compliance with CMS guidelines for Medicaid and Medicare DME services. Executed verification of provider credentials, including NPI and Tax ID numbers, and developed payment contracts tailored to specific health plans and provider services. Coordinated the implementation of benefit plans, including data import and system updates, for a variety of health plans such as Humana, Careplus, and Anthem Medicaid. Claims Examiner III Analyzed and processed Medicare and Medicaid DME, HH, and Infusion claims, ensuring compliance with CPT/HCPCS codes and ICD-10 standards. Reviewed and determined the disposition of home health claims, including the validation of documentation from RNs and LPNs, resulting in accurate claim approvals or denials. Managed claim adjustments for incorrect payments and processed corrected provider submissions, maintaining a departmental productivity benchmark of 125 claims daily. BupaCustomer Service Representative / Claim Processor Jan 2014 - Jan 2018 Delivered comprehensive customer service, responding promptly to inquiries from international and domestic callers, including healthcare providers and insurance members. Assisted with the pre-certification and authorization processes, ensuring international members received timely guarantees of payment for U.S. medical services. Managed medical records review and accurately interpreted CPT and ICD-10 codes to facilitate effective communication between members and the medical team. Upheld a 100% Quality Control score through meticulous handling of claims, benefits verifications, and maintenance of confidentiality for all member interactions. Transportation AmericaMember Service Representative 2012 - 2014 Provided daily assistance to over 250 riders in scheduling transportation services, ensuring precise coordination of pick-up and drop-off reservations. Maintained high levels of accuracy in data entry, recording rider destination addresses and contact information for seamless service delivery. Supported dispatchers in managing ongoing trips and facilitated communication between drivers and riders to address location issues and service enrollment inquiries. Member Service Representative Provided comprehensive assistance to riders by accurately scheduling transportation reservations and offering detailed information on driver ETAs and pickup times. Enhanced rider satisfaction by meticulously entering personal contact and destination details and facilitating effective communication between dispatchers and riders for seamless service delivery. Simply Healthcare PlansCustomer Service Representative 2010 - 2011 Resolved diverse Medicaid member inquiries, ensuring alignment with health plan's objectives and contributing to departmental goal attainment. Managed the update of member contact information following undelivered mail, facilitating continued access to essential healthcare documentation. Delivered bilingual customer support, addressing questions on insurance coverage, claims, authorizations, and provider information, enhancing member service experience. EDUCATIONHigh SchoolDiplomaSKILLSExcellent Problem-Solving Skills Good Follow-Up Abilities Willingness to Be Flexible and Adaptable to Changing Priorities Self-Starter, With an Ability to Work Independently and in a Team Environment Collaboration Documentation Communication |
