| | | 20,000+ Fresh Resumes Monthly | |
|
|
| |
Click here or scroll down to respond to this candidateCandidate's Name
PROFESSIONAL EXPERIENCEI have Over 20 years experience in many facets of the Health Insurance realm including Medical Office Management, Claims and Appeals, Customer Service, Provider Relations/Contract Negotiation and Accounts Receivable. I enjoy meeting new challenges and strive to excel in my work life.United Healthcare Remote Dec. 2021-presentRespond to and resolve, on the first call, customer service inquires and issues by identifying the topic and type of assistance the caller needs such as benefits, eligibility and claims, financial spending accounts and correspondenceHelp guide and educate customers about the fundamentals and benefits of consumer-driven health care topics to select the best benefit plan options, maximize the value of their health plan benefits and choose a quality care providerInitiate proactive outreach to members as needed, which may involve welcoming new members to our health plans, addressing gaps in care, reviewing coverage, and referring & enrolling them to internal specialists and programs based on their needs and eligibilityContact care providers (doctors offices) on behalf of the customer to assist with appointment scheduling or connections with internal specialists for assistanceAssist customers in navigating myuhc.com and other UnitedHealth Group websites and encourage and reassure them to become self-sufficientNet2Source Staffing-Customer Supply Chain 3 completion of 90 day contract Aug. 2020-Nov.2020US CENSUS 2020-2020 US Census Federal Employment Jun. 2020-Nov. 2020***COVID RESTRICTIONS*** Mar. 2020-Jun. 2020Centene/Superior Healthplan, San Antonio, Texas completion of 90-day contract Sept. 2018-Dec. 2018 Provider Services Rep IIReference current materials to answer escalated and complex inquiries from members and providers regarding claims, eligibility, covered benefits and authorization status mattersProvide assistance to members and/or providers regarding website registration and navigationEducate members and/or providers on health plan initiatives Provide first call resolution working with appropriate internal/external resources, and ensure closure of all inquiriesDocument all activities for quality and metrics reporting through the Customer Relationship Management (CRM) applicationProcess written customer correspondence and provide the appropriate level of follow-up in a timely mannerResearch and identify processing inaccuracies in claim payments and route to the appropriate team for claim adjustmentIdentify trends related to member and/or provider inquiries that may lead to policy or process improvements that support excellent customer service and impact quality and performance standardsWork with other departments on cross functional tasks and projectsMaintain performance and quality standards based on established call center metrics including turn-around timesI was consistently able to exceed Quality Standards for the duration of this 3-month contract. I received multiple Provider Nominations for Excellent Service.Medtronic, San Antonio, TexasPatient Fulfillment Services/Collector II Sept. 2017-March 2018Initiates follow-up activities with third-party payors regarding open claim balances; makes written and verbal inquiries to payors. Analyzes and problem solves account issues to full resolution.Reconcile claims/accounts to complete resolution, performing adjustment requests and updating patient accounts/claims online, utilizing appropriate transactions and consistently formatted notes that support future collection efforts and inquiries at both the insurance and customer (i.e. self pay) levels.Provides support for inquiries from internal and external customers regarding account/claim status. Maintains updated information on patient accounts.Handles internal and external customer inquiries regarding account status and account history.Performs eligibility verifications on patient accounts as new insurance plans/carriers are identified; updates information on expired insurance plans/carriers.Researches issues off-line as needed with payor/patient; conducts follow-up calls with customers, initiating conference calls between insurance carrier and patients to resolve customer concerns.Researches and initiates refund requests due to overpayments by payor and/or patient.Determines when claims/accounts are deemed uncollectable; recommends and initiates bad debt write-offs procedures.Meets or exceeds key performance indicators measuring productivity, quality, and service level as defined by Senior Management.Actively participates in team initiatives and in team status meetings. Additional team activities, projects, and workflow as assigned.During the duration of this 6-month contract, I was responsible for approximately $50 million dollars of Accounts Receivables/Month. Production and Quality Standards met on a regular basis.Reimbursement eXperts, San Antonio, Texas Nov. 2002 Dec. 2017Revenue Cycle Manager/AcquisitionsDemonstrated knowledge of HIPAA Privacy and Security Regulations by appropriately handling patient information(PHI).Receive, organize and maintain all coding and reimbursement periodicals and updates.Appropriately and correctly identify errors and re-file denied/rejected claims as they are received.Add modifiers as appropriate.Code narrative diagnoses and verify diagnoses.Analyze and interpret medical and surgical records to determine billable services.Thoroughly review remittance codes from EOBs/ARs.Evaluate the accuracy of provider charges including dates of service, procedures, level of care, locations, diagnoses, patient identification and other duties pertaining to claims payment.Post payments, charges and adjustments.Carefully prepare, review, and submit patient statements.Ensure timely and accurate claim submission through paper and electronic clearinghouse.Research CPT and ICD-9/10 coding for compliance and reimbursement accuracy.Maintain strict patient and provider confidentiality.Resourcefully use various coding books, procedure manuals and on-line encoders.Perform all auditing and reporting requirements on a monthly and yearly basis.Communicate with CPA and Physicians regarding all Income Projections and P&L. Review and approve all Payor contracts and agreements.Over the 15 years that I was with the company (Due to merger, the company no longer exists) I serviced multiple Physician groups, most specifically New Customer Acquisitions. Client satisfaction and practice profitability were INCREASED for all accounts. New business lines were added due to Client Referrals based on Provider Satisfaction Survey.VALUABLE SKILLSSuccess with various billing software programs such as MOMS/Datatel, Advanced MD, CRM, SAP, GE Centricity, Great Plains, SalesForce and others.Experience with EMR (Electronic Medical Records),HIPAA and PHI requirements.Electronic claims and appeals and reporting.IT procurement and installation/maintenance.Data verification and backup.Intermediate to Advanced Microsoft Office Suite.Training and Education.Familiar with Medicare/Medicaid and Most Payors, including Most Medicare/Medicaid HMO/MCOs. Advanced knowledge of Navinet, Availity, TMHP, most Payor portals. Current Property and Casualty License |
