Category: BPO

         CLAIMS SUBJECT MATTER EXPERT         Professional Summary    Experienced Customer Service Representative with over 10 years of experience
Worked in Healthcare Industry for over 8 years with Humana, Passport and Excellus BCBS of NY
Successfully trained seasonal associates for Open Enrollment and worked as a Client Subject Matter Expert for SHPS, Inc.      Skills          HCPCS Coding Guidelines  Understands anesthesia coding  Insurance and collections procedures  Understands insurance benefits  DRG and PC grouping  Ambulance coding familiarity  Composed and professional demeanor  Research and data analysis  Resourceful and reliable worker  Excellent problem solver  Close attention to detail  Medical terminology expert  Billing and collection procedures expert       •Office support (phones, faxing,  filing)     •Excellent verbal communication                   Adept m ulti-tasker   Office support (phones, faxing, filing)    Fast Learner  Records management professional •ICD-10 (International Classification of Disease Systems) •Familiar with commercial and private insurance carrier •Insurance and collections procedures •DRG and PC grouping •Understands insurance benefits •Ambulance coding familiarity •Composed and professional demeanor •Research and data analysis •Excellent problem solver •Office management professional •Close attention to detail •Excellent verbal communication  ​                   Work History       Claims Subject Matter Expert  ,     09/2016   to   12/2016     Company Name   –   City  ,   State          ·       Worked any other special projects assigned by management       ·       Responsible for meeting claims production goal of 200 claims per
day       ·       Processed professional HCFA 1500 ambulance, anesthesia, labs,
office visits etc. professional HCFA 1500       ·       Responsible for claims processing for the Medicaid plans for HMO 7
University Health and HMO 9 AHCSS       ·       Worked as a claims subject matter expert for Banner Health                   Benefit Plan Admin./Client Service Expert  ,     05/2016   to   09/2016     Company Name   –   City  ,   State          ·       Responsible for duties in    support o  f all departmental efficiencies
as assigned by management       ·       Scheduled refills per the patients' plan benefit       ·       Keyed orders and sent for fulfillment       ·       Processed RX refills for customers       ·       Assisted with outbound calling to providers, patient and
pharmacies to obtain additional info need to process the RX refill,      ·     Answered incoming calls                 Patient Access Rep I  ,     07/2015   to   03/2016     Company Name   –   City  ,   State        ·      Responsible for duties in support of departmental
efficiencies which may include: but not limited to performing scheduling,
registration, patient pre-admission and admission, reception and discharge
functions.      ·        Verify
medical benefits and eligibility with payers and calculate patient liability
collection amounts      ·        Completes
the whole patient financial clearance process; including educating patients on
liability and collection of patient liabilities due.      ·        Completes
all account documentation and enters the correct activity code when required.      ·         Secures
insurance authorizations for services and updates account accordingly      ·        Performs
payment reconciliation & secured payment entry in adherence to financial
& cash control policies and procedures                           Claims Subject Matter Expert/DST  ,     07/2015   to   07/2015     Company Name   –   City  ,   State        ·     Worked as a Claims Examiner for DST Solutions based out of
Delaware     ·     Responsible for processing Commercial and Medicare Plans.     ·     Adjusted backlog claims using the clients claims system for
adjudication     ·     Knowledgeable of Citrix platform for applications.      ·     Utilized Claims Matrix to determine authorization for Delivery,
Well baby Newborn, Inpatient Claims, Nursing Home etc.                          Claims Examiner  ,     07/2014   to   05/2015     Company Name   –   City  ,   State        ·     Worked as a Claims Examiner for client Kaiser Permanente Southern
California.     ·     Responsible for data processing incoming Hospital UB's for
Medicare/ KPSA Plan.     ·     Contract interpretation to validate proper payment logic for claim
adjudication.     ·     Identify billing and coding errors and submit documentation to
provider's if necessary for corrected claims forms to be sent in with the
Medicare compliance guidelines.     ·     Adjudicate Replacement, Late charge claims etc. accordingly per
client's guidelines for processing.     ·      Proficient
in Microsoft Word, Excel, Power point, Outlook, Internet Explorer, CMS Pricers,
DRG Calculator, ICD-9, CPT, Basic Office Systems and various web applications                           Claims Subject Matter Expert  ,     05/2013   to   05/2014     Company Name   –   City  ,   State       ·     Worked as a contracted claims expert for Excellus BCBS of NY      ·     Responsible for claims processing for the HOME Commercial,
Medicare and Medicaid plans     ·     Processed claims with the HOST side of the plan updating provider
files and credentials to support claims adjustment.     ·     Worked any other special projects as assigned by management.               Provider Claims Service Unit Representative I  ,     03/2008   to   11/2012     Company Name   –   City  ,   State       ·        Responsible for immediate responses to
incoming provider calls regarding claims issues.        ·        Process incoming correspondence from
providers on claims issues that need to be resolved for Passport Health
(Medicaid) and Passport Advantage.      ·        Reprocessing claims as identified through
incoming phone calls or submitted by provider relations staff.        ·        Identifying systematic and procedural
issues resulting in claims processing errors and initiating action to resolve
those issues.      ·        Documenting calls, problems, and resolutions
for future reference      ·        Proficient in Microsoft Word, Excel, Power
point, Outlook, Internet Explorer, Facets, IKA Systems, CMS Pricers, DRG
Calculator, ICD-9, CPT, Basic Office Systems and web application      ·     Worked special projects as assigned by management               Benefits Plan Administration/ Eligibility & Enrollment/Client Service Expert  ,     05/2004   to   03/2008     Company Name   –   City  ,   State       ·        Answered incoming
calls regarding eligibility, claims processing, and billing inquires.      ·        Administered employee
group benefits for retirees, active, long term disability, and cobra
participants      ·        Resolved Issues
for billing, carrier eligibility, etc.      ·        Organized special
projects such as web inquiry responses, updating accurate information in our
knowledge base customer service tool as assigned by management      ·      Team
lead/ Initiated training for full-time and temporary associates of ongoing call
center and open enrollment.                Customer Service Claims Specialist-Chicago Medicare/ Commercial/ Medicaid  ,     04/2001   to   02/2003     Company Name   –   City  ,   State        ·        Supported Chicago
Medicare , Medicaid and Commercial Markets      ·        Received inbound
and outbound calls from insured members, clients, brokers, agents and providers      ·        Mailed any
related correspondence such as enrollment material, forms and brochures to
members.      ·        Processed medical
claims that needed adjustment      ·        Knowledgeable of
DRG, ICD-9, CPT coding             Managed customer calls effectively and efficiently in a complex, fast-paced and challenging call center environment.  Accurately documented, researched and resolved customer service issues.  Managed high call volume with tact and professionalism.  Acted professionally and patiently when addressing negative customer feedback.  Resolved service, pricing and technical problems for customers by asking clear and specific questions.  Effectively managed a high-volume of inbound and outbound customer calls.          Claims Examiner  ,     07/2014   to   05/2015     Company Name   –   City  ,   State     ·  Worked as a Claims Examiner for client Kaiser Permanente Southern California. ·   Responsible for data processing incoming Hospital UB's for Medicare/ KPSA Plan.  ·   Contract interpretation to validate proper payment logic for claim adjudication. ·  Identify billing and coding errors and submit documentation to provider's if necessary for corrected claims forms to be sent in with the Medicare compliance guidelines.  ·  Adjudicate Replacement Bill Type , Late charge claims etc. accordingly per client's guidelines for processing. Proficient in Microsoft Word , Excel, Power point, Outlook, Internet Explorer, CMS Pricers, DRG Calculator, ICD-9, CPT, Basic Office Systems and variousweb applications    Precisely completed appropriate claims paperwork, documentation and system entry. Thoroughly researched newly identified diagnoses and/or medical procedures to expand skills and knowledge. Resourcefully used various coding books, procedure manuals and on-line encoders. Actively maintained current working knowledge of CPT and ICD-9 coding principles, government regulation, protocols and third party requirements regarding billing.           Education      Bachelor of Science  :   Psychology  ,   Current     Liberty University   -   City  ,   State    Psychology/ Christian Counseling  Administration  Advocacy  Case Management  Community Relations  Counseling  Mental Health Services Programming       Certification in Medical Coding May 2017  :         Ashworth College   -                Skills    AS400, balance, Basic, benefits, billing, brochures, Calculator, call center, CMS, CPT coding, CPT, credit, client, clients, customer service, forms, ICD-9, Internet Explorer, Team lead, team leader, Microsoft Access, Excel, Office, Outlook, PowerPoint, Power point, Word, Microsoft Word, Police, Coding, sales, phone