Category: HEALTHCARE

         CLAIMS SERVICE SPECIALIST         Professional Summary    Medical Billing Specialist with  3  years experience in a fast-paced, multiple client medical billing company. Researched and denied claims and submitted appeals. Familiar with health billing and collections. Advanced knowledge of claims processing and pre-authorizations.       Skills          Medical terminology expert  ICD-10 (International Classification of Disease Systems)  Billing and collection procedures expert  Hospital inpatient and outpatient records  Inpatient records coding proficiency  Outpatient surgery coding specialist  HCPCS Coding Guidelines  Familiar with commercial and private insurance carriers  Insurance and collections procedures  DRG and PC grouping  Understands insurance benefits  Research and data analysis  Close attention to detail  Adept m ulti-tasker   Office support (phones, faxing, filing)  Excellent verbal communication      MS Windows proficient  Customer service award  Skilled trainer  Excellent time management skills  Microsoft Outlook, Word and Excel  MS Office expert  Supervisory training  Accomplished leader  Resource management expertise  Knowledge of Medicare statutes and regulations            Work History      Claims Service Specialist  ,     10/2013  
                            to   06/2014     Company Name   –   City  ,
                          State      Filed claims per NextGen system Discussing coverage's and liability with insured, claimant, and body shops.  Also spoke with lienholders and medical providers.  Typing and data entry Obtaining police reports to determine liability for claims Reviewing estimates and correspondence faxed, mailed, and emailed in.  Issuing payments and scheduling rental reservations for insured and claimants.  Precisely completed appropriate claims paperwork, documentation and system entry.     Correctly coded and billed medical claims for various hospital and nursing facilities.  Verified patients' eligibility and claims status with insurance agencies.  Performed qualitative analysis of records to ensure accuracy, internal consistency and correlation of recorded data.  Interacted with providers and other medical professionals regarding billing and documentation policies, procedures and regulations.  Accurately posted and sent out all medical claims.  Submitted electronic/paper claims documentation for timely filing.         Claims Specialist   ,     10/2011  
                            to   07/2012     Company Name   –   City  ,
                          State      Correctly coded and billed medical claims for various hospital and nursing facilities.  Meticulously identified and rectified inconsistencies, deficiencies and discrepancies in medical documentation.  Diligently filed and followed up on third party claims.  Determined prior authorizations for medication and outpatient procedures.  Pre-certified medical and radiology procedures, surgeries and echocardiograms.  Researched questions and concerns from providers and provided detailed responses.  Reviewed, analyzed and managed coding of diagnostic and treatment procedures contained in outpatient medical records.  Researched CPT and ICD-9 coding discrepancies for compliance and reimbursement accuracy.  Actively maintained current working knowledge of CPT and ICD-9 coding principles, government regulation, protocols and third party requirements regarding billing.  Managed collections claims for unpaid bills against the estates of debtors.  Accurately posted and sent out all medical claims.  Submitted electronic/paper claims documentation for timely filing.  Performed billing and coding procedures for ambulance, emergency room, impatient and outpatient services.  Precisely evaluated and verified benefits and eligibility.  Responded to correspondence from insurance companies.  Identified and resolved patient billing and payment issues.  Confidently and adeptly handled claim denials and/or appeals.  Evaluated patients' financial status and established appropriate payment plans.  Reviewed and resolved claim issues captured in TES/CLAIMS edits and the clearing house.  Examined patients' insurance coverage, deductibles, possible insurance carrier payments and remaining balances not covered under their policies when applicable.  Updated patient financial information to guarantee accuracy.         Subject Matter Expert   ,     07/2012  
                            to   10/2013     Company Name   –   City  ,
                          State         Initiated audit process to evaluate thoroughness of documentation and maintenance of facility standards.  Created and maintained computerized record management systems to record and process data and generate reports.  Supervised 15+ claims specialist and answered work-related questions via chat instant messaging system   Took escalated calls from providers providing excellent customer service and solving all claim related problems.   Manually reprocessed claims for accuracy after being sent back by facilities with questions about denials and non-payment.   Cross-trained and backed up other customer service managers.  Solved unresolved customer issues.  Assumed ownership over team productivity and managed work flow to meet or exceed quality service goals.  Identified individual development needs with appropriate training.  Effective liaison between customers and internal departments.  Defused volatile customer situations calmly and courteously.         Healthcare Agent  ,                Education      Associate of Science  :   Medical Billing and Coding   ,  Current     Central Piedmont Community College   -   City  ,
                              State      Coursework in Business, Accounting and Healthcare Administration  Coursework in Healthcare Management  Coursework in Healthcare Administration  Coursework in Medical Front Office Assisting         High School Diploma  :     10 2007           Skills    accounting, benefits, billing, communication skills, customer satisfaction, customer service, customer service training, data entry, focus, insurance, listening, Medical Billing, police, problem resolution, Coding, Read, scheduling, supervisor, Typing, type