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Click here or scroll down to respond to this candidateCandidate's Name
Laurel, MD Street Address
EMAIL AVAILABLEPHONE NUMBER AVAILABLEDetail-oriented,empathetic claims, enrollment and credentialing Service Specialist with extensive experience in provider/member enrollment, claims and billing across healthcare and financial services. Specialized in handling claims, denials, appeals, utilization applications and records for managed care advisors, leveraging strong communication skills and technical proficiency to resolve customer issues efficiently. Eager to bring expertise in healthcare reimbursment, provider and member services to a dynamic team.Work ExperienceClaims Services Team LeadMCA Sedgwick / World Trade Center Health Program-Remote November 2022 to Present Act as the primary liaison between providers, internal staff, and members for claims adjudication. Receive, confirm, and process appeals, denials, and requests for timely claim review and processing. Accurately review CMS 1500 and UB 04 forms for processing in Luminex claims management system. Obtaining, Maintaining and updating of medical records, for timely and accurate process. Ensuring data integrity through timely and effective documentation of all communication with providers. Maintain updated knowledge of MCA policies and procedures. Monitoring "Care Conduit" EMR system to ensure promt response to member questions to ensure timely process. Accurately document communication and update claim status changes. Analyze claim errors and medical records to advise providers on denials and underpayments.Provide EOBs, medical records, compliance forms, and remittance advice to service providers. Submit completed claims to clearing house.Customer Service BillingGastrointestinal AssociatesMay 2018 to October 2022Call Center Oversee daily Billing Department functions, including medical coding, charge entry, claims, payment posting, and reimbursement management. Examine patients encounter forms to verify diagnosis codes and reconcile codes against services rendered Accurately input procedure and diagnosis codes into billing software to generate invoices. Used electronic charge capture practices such as billing and account receivables(BAR) system and medical billing clearinghouse accounts to submit codes and invoices on time. Follow up on past due invoices and delinquent accounts to reduce number of unpaid and outstanding balances. Processed and confirmed patients' coverage and insurance information. Document patient data and medical records and perform routine medical record audits to comply with MCA requrements.Customer ServiceKaiser Permanente Call CenterNovember 2015 to January 2018 Handled member and provider inquiries about benefits elegibility. Responded empathetically to member concerns and complaints regarding Health Plan benefits, account status, payment history, and medical services. Initiated contact with relevant Health Plan, medical group, and facility personnel to create referrals and establish initial member encounter. Resolved problems by clarifying issues, researching, exploring answers, and implementing solutions. Receive medical records and file faxes medical records. Provided EOB of processed claims to upon member and provider request. U.S. General Service Administrator (GSA)March 2011 to September 2014CustomerService Help Desk Provided technical assistance to GSA staff by evaluating and prioritizing complaints and identifying device and program issues. Created, opened, closed, and managed user accounts. Reset passwords and unlocked accounts to ensure user access to the database. Utalized Sales Force to create ticket escalation to request field services work order for complex issues. Assisted new users in downloading necessary documents, accessing, and using software. Ensured that all users were using the most up-to-date software and safety precautions. Call Center RepresentativeChevy Chase BankJanuary 2008 to December 2010Inbound & Outbound Calls Assisted customers with various banking products and services by receiving inbound and making outbound calls. Helped customers lock and replace lost or stolen cards. Enhanced the customer's banking experience by offering comprehensive products and services. Assisted customers in flagging and notifying them of unusual account activity to prevent fraud or identity theft. Maintained updated knowledge of all bank products, services, procedures, and laws. EducationLPN in Licensed Practitioner NursePrince Georges Community College - Largo, MDJanuary 2007 to December 2009Laurel High School - Laurel, MDSkills Expertice in Medical insurance Program Policies and terminology Strong verbal and written communication skills Effective problem-solving and issue resolution capabilities Excellent organizational, Task and time management skills Adaptability to effectively navigate multiple evolving technologies simultaneously. Commitment to Customer Service Excellence and satisfaction Medical Insurance Claims Support and Processing Credentialing and Enrollment process liason. Billing and Administrative Support Data Entry and Clerical Skills Planning Scheduling Case Management Technological Proficiency in Microsoft Office Google Workspace CRM tools SharePoint Acrobat Application Salesforce and EMR systems TECHNICAL SKILLS: Microsoft (Word, Excel, PowerPoint, Outlook) SharePoint Google Workspace Acrobat Programs: Remedy Software CRM (Salesforce) EMR systemsCertifications and LicensesLPN |
