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Click here or scroll down to respond to this candidateCandidate's Name , ACS, ALMIEMAIL AVAILABLELINKEDIN LINK AVAILABLEStreet Address E Park StreetPrinceton MO Street Address (C) PHONE NUMBER AVAILABLESUMMARYExperienced Accounts Receivable Representative and Claims Analyst with over 25 years experience in the medical and insurance fields.Expertise Includes:HIPAA trainedEffective planningOrganizingProblem solvingMulti-TaskingManaging heavy volume and functioning well under pressurePossess very strong interpersonal and leadership skillsPROFESSIONAL EXPERIENCEHealth Partners Plans2020-PresentMember Relations Philadelphia, PAPrimary Responsibilities:Educate callers about Health Partners plan with the intent of retaining members.Provide high levels of service.Report on trends and issues which impact the membership.Collaborate with internal departments to facilitate resolutions to members issues and concerns.Respond to member and member-related calls in a courteous, professional& efficient manner providing timely follow-up to requests for information and service.Participate in and conduct new member orientation outreach on a monthly basis as assigned.Answer eligibility, benefits and provider inquiries, assuring that members receive service, use the plan correctly and gain a high level of satisfaction with the plan.Maintain call records, logs and other documentation in accordance with departmental requirements.Operate MIS and telephone systems effectively and efficiently, following established protocols for security, transfer and information exchange.Participate in appropriate staff meetings and training sessions, reporting on trends and issues which impact members and Health Partners as a whole.Attend monthly meetings.Perform other clerical and support tasks as assigned.Reliance Standard Philadelphia, PA2018- 2020LTD Claims ExaminerPrompt and thorough investigation of claims within departmental and regulatory guidelines.Interprets and administers contract provisions including, but not limited to, eligibility, covered monthly earnings, definition of Total Disability, verification of applicable offsets and pre-existing investigations.Develops implements and modifies disability management plan to establish strategy and manage outcome.Documents claim file actions and telephone conversations appropriately.Refers claim activity outside authority level to Supervisor/Manager for review.Pro-actively communicates with claimants, policyholders, physicians to resolve investigations issues.Establishes, communicates and manages claimant and policyholder expectations.Utilizes most efficient means to obtain claim information.Fully investigates all relevant claim issues, provides payment or denials promptly and in full compliance with departmental procedures and Unfair Claims Practice regulations.Responds to customer service issues within required timeframes.Involves technical resources (Social Security Specialist, medical resources, and vocational resources) at appropriate claim junctures.Refers claims above ability to a supervisor/manager.Demonstrates ability to independently investigate, evaluate and adjudicate claims of moderate degree of complexity.Supports relationships with technical resources to achieve appropriate outcomes.Actively contributes to departmental service, quality and production objectives.Remains current with all corporate and disability management practices.Collaborates with team members and management in identifying and implementing improvement opportunities.May mentor less experienced examiners.Assists in review and assessment of claim settlement opportunities.Collaborates with management on claims with high degree of complexity.All other duties as assigned.Reliance Standard Philadelphia, PA2017-2018Customer Care CenterHandles customer complaints and inquiries in a timely and courteous manner.Provides information on in-force products to Agents, Policyholders and Employees.Communicates contract language in terms callers will understand.Resolves with customers a wide variety of problems.Provides clear and concise information on problems that require research beyond thatwhich can be handled by a Representative.Maintains a log of incoming calls from customers and field personnel.Follows through to ensure that problems and requests are handled satisfactorily.Follows up on telephone inquiries.Communicates with Policyholders and Agents on policy changes.Completes specific projects relating to policies.Assists other departments in handling customer service problems.Understand the process for address and correspondent changesAbility to discuss electronic billing and provide information on how to download afree upgrade or enroll online.Provide assistance with questions on Smart Choice, VIP and other products as theybecome available.All other duties as assignedAria-Jefferson Health Physicians Services Philadelphia, PA2015-2017Collections/BillingPlaced follow-up calls to insurance companies for claims with open dates of serviceResolved disputes and denials that may have been received as a reply rather than paymentDocumented and updated all notes pertaining to patient cases into the computer systemSorted through daily mail and correspondence submitted by the insurance companiesGathered necessary information needed by the Medical Billers to post medical paymentsPosted payments and made adjustments to patient ledgersResubmitted claims. Identified and trended consistent problems with various payersCoordinated special projects as assignedMed Protect LLC2012-2015Global TRICARE Service Center (GTSC) Beneficiary Service RepresentativeProcess enrollment/disenrollment and portability using the Defense Online Enrollment System (DOES).Assigns primary care managers (PCM) to TRICARE Beneficiary as appropriate.Verifies eligibility information for remote beneficiaries.Researches and interprets benefits, policies and procedures to military staff, remote site Points of Contact (POCs), and beneficiaries using TRICARE Policy Manuals as well as other resourcesProvide customer support to the Military Treatment Facility (MTF) Commander and or the TRICARE Area Office staff as directed by the Regional Lead, Deputy Program Manager or Program Manager.Providing education and enrollment information to beneficiariesOther various duties as assigned.Apollo Health Street Conshohocken, PA 2010 - 2011Collections/BillingPerformed Follow-up with insurance companies for outstanding hospital claims and obtain payments in a timely mannerContacted patients for insurance information or pending informationResubmitted claims. Identified and trended consistent problems with various payersCoordinated special projects as assignedDr. William J OBrien III Bristol, PA 2009 - 2010Collections/BillingPlaced follow-up calls to insurance companies for claims with open dates of service for Workmans Compensation, Slip and fall and Motor VehicleResolved disputes and denials that may have been received as a reply rather than paymentWorked with PI Coordinators and Front Desk personnel to resolve disputesDocumented and updated all notes pertaining to patient cases into the computer systemSorted through daily mail and correspondence submitted by the insurance companiesFollowed-up on patient cases by contacting the assigned attorney, as well as the PI CoordinatorGathered necessary information needed by the Medical Billers to post medical and/or injury paymentsScanned documentation into the computer system to assure the information is readily available to those who may need it to assist the attorneyPosted payments and adjusted patient ledgersAlliance One Receivables Trevose, PA 2007 - 2008Collections/BillingContacted customers regarding past due credit card amounts owed before charge-offHelped and educate customers with payment options and work closely with client for various assistance programsSkip traced accounts to find customersVarious other duties as assignedArc Group Associates, Jenkintown, PA 2006 - 2007Collections/BillingPerformed Follow-up with insurance companies for outstanding hospital claims and obtain payments in a timely mannerContacted patients for insurance information or pending informationResubmitted claims. Identified and trended consistent problems with various payersCoordinated special projects as assignedHome Care Supply/Praxair, Huntington Valley, PA 2004 - 2006Collections/BillingWorked with assigned insurance companies on a daily basis to receive information necessary to bill and collect for durable medical equipment rentals and salesManaged Keystone 65 and Keystone Health Plan East - revamped and collected the back billing for these insurance plansManaged Personal Choice, Personal Choice 65, AmeriHealth Personal Choice and AmeriHealth AdministratorsReviewed edit list to ensure that billing is accurately submitted to the corresponding insurance companyManaged cash input and output for the Company; billing and collectionsHandled general customer service questions to existing and prospective patientsCoordinated the A/R reportDouble H Plastics, Inc., Warminster, PA 2003 - 2004Customer Service RepresentativeMaintained relationships between outside vendors and external client account managersProcessed client requests for both versa form lids and plastic core productsCompiled and distributed inventory analysis reports for customersCreated procedure manual for the Customer Service DepartmentDirected phone calls to appropriate personnel within the companyManaged billing for both versa form lids and plastic coresAon Select/CBCA, Horsham, PA 1996 - 2003Claims AnalystProcessed Medicare Supplement Claims, PPO Claims and various other health claimsMaintained an average of 135 claims daily or 675 claims per weekProvided superior customer service to patients and providersManaged general office duties such as: filed and copied documents as neededCoordinated special projects as assignedEDUCATIONBucks County Technical School, Nursing (1984)Bensalem Senior High SchoolHigh School Diploma: Received Perfect Attendance Award for all 4 years of schoolCOMPUTER SKILLSAS/400, Word, Excel, Windows, Lotus Notes, Dezine, Mestamed, Doctor.com, E-Premise, Emedeon, Medicare system, Navi net, CPSI, Deers/Does, etc.Obtained ADP2/IT2 Clearance as of 5-2012Obtained ACS ALMI and FLMI 1 2017 |
