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Click here or scroll down to respond to this candidateCandidate's Name
Decatur, GA Street Address PHONE NUMBER AVAILABLE EMAIL AVAILABLEProfessional SummaryData Management Specialist with strong data collection and analysis capabilities. Over 10 years of experience developing, disseminating and fixing datasets. Familiar with various statistical tools and Workday, Citrix, Portico, and CenProv software. Self motivated candidate with strong organizational skills. Ready to help team achieve company goals and maintain a position that offers professional challenges utilizing interpersonal skills, excellent time management and problem-solving skills. SkillsCPT and HCPCS codingKnowledge of HMOs, Medicare, Medicaid,And Ambetter productsInternal Medicine billingHIPAA compliance and strong planning skillsManaged Care contract knowledgeElectronic Medical Record (EMR) softwareGood written communication skillsTeam player with positive attitudeCenProv, Portico, SharePoint and AmisysproficiencyData OperationsWork HistoryProvider Data Management Specialist, II 06/2020 to Current CENTENE CORPORATION Atlanta, GASpecializing in managing and resolving complex provider data issues such as billing and service locations, name change, NPI updates, and more.Confidently enrolling Providers and facilities into multiple plans associated with Centene CorporationUsing Excel and Micro Soft skills to participate in reconciliation on SharePoint and provider special data projects.Validate provider's credentialing and contracting status Maintain accurate databases and reports to monitor network compliance with State requirementsPerform excellent communication skills with fellow employees to complete tasks efficiently. Conducted complex data management with SQL server and T-SQL. Formulated techniques for quality data collection to meet expected adequacy, accuracy and legitimacy targets.Facilitated review and selection of data acquisition citations and applicable standards. Verified compliance with data retention requirements by managing document catalogues for long-term archival of data associated with contract closeouts. Customer/ Provider Member Services, II 11/2014 to 06/2020 CENTENE CORPORATION Atlanta, GAHaving ability to multitask by entering data and ability to listen while providing excellent service for members and providers of health planRecommended specific products and services in alignment with individual needs, requirements and specifications.Met customer call guidelines for service levels, handle time and productivity. Successfully complete first call solutions by communicating with providers, pharmacies, case workers, and insurances companies when neededScreen for eligibility, benefits, and identify members without PCP Serve as claims inquiry expert by providing payment, denials, and solutions for claims information Assist with prior authorizations, provider account knowledge, and claim information through TruCare, Portico, Omni, and Amisys Technology Systems Validate provider's credentialing, enrollment, contracting status, and various related data informationPerform general administrative tasks in support of assigned department Verifying eligibility and claims information for members while problem solving Followed-through on all critical inter-departmental escalations to increase customer retention rates.Working in Behavioral Health department with sensitive guidance, while assisting in activities related to medical and psychosocial aspects of utilization and coordinated care. Trained staff on operating procedures and company services. Reimbursement Specialist/Office Assistant 02/2011 to 06/2014 J. MANUEL PATINO, M.D. Atlanta, GARecorded and filed patient data and medical records Prevented delays and claim denials by correcting information prior to submission. Carefully reviewed medical records for accuracy and completion as required by insurance companiesBuilt proactive, client-specific edits into system to prevent future denials. Assigned additional diagnosis codes based on specific clinical findings (laboratory, radiology and, pathology reports as well as clinical studies) in support of existing diagnoses Wrote clear and detailed clinical phone messages for physicians Performed Georgia and federal regulations compliance audits related to documentation and reporting.Efficiently performed insurance verification and pre-certification and pre-authorization functions. Prepared and attached all required claims documentation including referrals, treatment plans or other required correspondence to reduce incidence of denials Helped minimize escalations by reaching out to clients in advance of expected problems. Followed up on denied and unpaid claims to resolve problems and obtain payments. Carefully prepared, reviewed and submitted patient statements Contributed knowledge to help improve financial management, billing and tracking systems. Compiled department-specific reports to help senior managers identify trends and improve progress.Delivered timely information to insurance representatives to resolve common and complex issues.Posted charges, payments and adjustmentsConfirmed patient information, collected co-pays and verified insurance. Employed clinical and billing codes expertise to correct billing inconsistencies. Created documents in accordance with payer guidelines and submitted to appropriate parties. EducationASSOCIATE OF SCIENCE: MEDICAL ADMINISTRATION MANAGEMENT 01/2014 University of Phoenix - Atlanta, GABusiness AdministrationHealthcare ManagementHealth Information AdministrationGPA: 3.69CERTIFICATION: MEDICAL BILLING AND CODING ADMINISTRATION 01/2010 Stanford and Brown College - Atlanta, GAMedical Billing and CodingCertificationsCertified Coding Specialist and Medical Office Admin Certificate, Sanford and Brown College, 05/2010 |
