| | | 20,000+ Fresh Resumes Monthly | |
|
|
| |
Click here or scroll down to respond to this candidateCandidate's Name
Indianapolis, IN Street Address
PHONE NUMBER AVAILABLE EMAIL AVAILABLEPROFESSIONAL SUMMARYTo seek and maintain full-time position that offers professional challenges utilizing interpersonal skills, excellent time management and problem-solving skills. SKILLSProficient in Microsoft Word, Excel, PowerPoint, Outlook, Multiple Health InsuranceWebsites; Excellent Customer Service; StrongInterpersonal SkillsAuthorization InputBenefits VerificationsRegulatory DocumentationInsurance AuthorizationsWORK HISTORYPremera Blue CrossProvider Service Representative Mountlake Terrace, WA September 2023 March 2024 Answered inbound calls from hospital, medical practices (medical/surgical and dental) and substance abuse/mental health facilities to answer medical policy questions insurance inquiries. Provide up-to-date benefit quotes stating Copay, Coinsurance, and out of pocket values for specific medical procedures. Research CPT codes for various medical procedures giving the accurate benefit quote and supporting medical policies that may influence medical Claims approval. Review medical policy bulletins if applicable for providers with claim denials Forwarded claims to appropriate departments for review and adjustments when claim denial errors are discovered. Explain provider offset/refunds to providers when payments are recouped for claims paid in error. OSCAR HEALTH INSURANCEClinical Review Processor/Clinical Appeals Liaison Tempe, AZ March 2019 - October 2022 Intake, assessment, coordination of appeals, and liaising with several external agencies including state regulators and other third parties responsible for health plan administration and Oscar's internal Clinical Review TeamAssess eligibility of appeals, gathered case documentation and medical records to ensure that requested or established timeframe requirements are met Outreach to providers for medical records and to members as needed to gather details relevant to appealsCoordinated with upper level management such as Medical Directors with level 1, 2 and 3 appeals in order to represent members' appeal accurately Advocated for members to ensure that members understood their appeal rights and had clear understanding of appeal process.Ability to read, interprets, and analyzes documents such as reports, guidelines, plan documents and summary plan descriptions.Responsible for training for all new Appeals Specialists on all Regulations and Operations MCKESSON HEALTH SOLUTIONCustomer Service Representative/Insurace Specialist November 2017 - May 2018 Verifies insurance benefits for new patient referrals Re-verifies insurance benefits for existing patients Reviews all medical documentation against medical policy and initiates pre-determination, pre-certification, and authorizationsFollow-up on pending pre-certifications and/or pre-determinations Completes special projects as assignedPerforms other job related duties as assignedTake inbound calls from patients to locate treatment providers. Reimbursement Insurance Specialist July 2014 - July 2016 Contact payers to verify patient eligibility and product specific coverage information Provide claims assistance, including billing and coding instructions, to physicians and/or office staffProvide accurate and timely follow-up to all reimbursement inquires in accordance with program guidelinesObtain and compile payer specific information for reimbursement database. TOYOTA FINANCIAL SERVICESCollections Customer Service Representative August 2016 - September 2017 Retrieving payment history from available systems and clearly communicating the status to the customerAnalyzing account characteristics and working with customers to resolve their issues, persuading them to bring their account currentUtilizing all collection tools available to maintain delinquencies and losses at or below Customer Service Center objectives.AETNAClaims Benefit Specialist February 2010 - October 2013 Claims processing for Mercy Care Plan and Illinois Integrated Plan Analyze and approve routine claims that cannot be auto adjudicated Coordinate responses for routine phone inquiries and written correspondence related to claim processing issuesFacilitate training when considered topic subject matter expert. HEALTH CHOICE OF ARIZONAClaims Representative October 2008 - January 2010 Responsible for adjudicating incoming Institutional and Physician claims Give information regarding claims payment.BLUE CROSS BLUE SHIELD OF ARIZONAClaims Representative May 2006 - February 2008Process Institutional and Physician claimsExplain to subscribers and group representatives contract benefits, and changes in coverage Give information regarding claims paymentConduct research and updates on a current daily basis. |
