CLAIMS SUBJECT MATTER EXPERT Professional Summary Experienced Customer Service Representative 10 years experience Worked Healthcare Industry 8 years Humana, Passport Excellus BCBS NY Successfully trained seasonal associates Open Enrollment worked Client Subject Matter Expert SHPS, Inc. Skills HCPCS Coding Guidelines Understands anesthesia coding Insurance collections procedures Understands insurance benefits DRG PC grouping Ambulance coding familiarity Composed professional demeanor Research data analysis Resourceful reliable worker Excellent problem solver Close attention detail Medical terminology expert Billing collection procedures expert •Office support (phones, faxing, filing) •Excellent verbal communication Adept ulti-tasker Office support (phones, faxing, filing) Fast Learner Records management professional •ICD-10 (International Classification Disease Systems) •Familiar commercial private insurance carrier •Insurance collections procedures •DRG PC grouping •Understands insurance benefits •Ambulance coding familiarity •Composed professional demeanor •Research data analysis •Excellent problem solver •Office management professional •Close attention detail •Excellent verbal communication ​ Work History Claims Subject Matter Expert 09/2016 12/2016 Company Name – City State · Worked special projects assigned management · Responsible meeting claims production goal 200 claims per day · Processed professional HCFA 1500 ambulance, anesthesia, labs, office visits etc. professional HCFA 1500 · Responsible claims processing Medicaid plans HMO 7 University Health HMO 9 AHCSS · Worked claims subject matter expert Banner Health Benefit Plan Admin./Client Service Expert 05/2016 09/2016 Company Name – City State · Responsible duties support f departmental efficiencies assigned management · Scheduled refills per patients' plan benefit · Keyed orders sent fulfillment · Processed RX refills customers · Assisted outbound calling providers, patient pharmacies obtain additional info need process RX refill, · Answered incoming calls Patient Access Rep I 07/2015 03/2016 Company Name – City State · Responsible duties support departmental efficiencies may include: limited performing scheduling, registration, patient pre-admission admission, reception discharge functions. · Verify medical benefits eligibility payers calculate patient liability collection amounts · Completes whole patient financial clearance process; including educating patients liability collection patient liabilities due. · Completes account documentation enters correct activity code required. · Secures insurance authorizations services updates account accordingly · Performs payment reconciliation secured payment entry adherence financial cash control policies procedures Claims Subject Matter Expert/DST 07/2015 07/2015 Company Name – City State · Worked Claims Examiner DST Solutions based Delaware · Responsible processing Commercial Medicare Plans. · Adjusted backlog claims using clients claims system adjudication · Knowledgeable Citrix platform applications. · Utilized Claims Matrix determine authorization Delivery, Well baby Newborn, Inpatient Claims, Nursing Home etc. Claims Examiner 07/2014 05/2015 Company Name – City State · Worked Claims Examiner client Kaiser Permanente Southern California. · Responsible data processing incoming Hospital UB's Medicare/ KPSA Plan. · Contract interpretation validate proper payment logic claim adjudication. · Identify billing coding errors submit documentation provider's necessary corrected claims forms sent Medicare compliance guidelines. · Adjudicate Replacement, Late charge claims etc. accordingly per client's guidelines processing. · Proficient Microsoft Word, Excel, Power point, Outlook, Internet Explorer, CMS Pricers, DRG Calculator, ICD-9, CPT, Basic Office Systems various web applications Claims Subject Matter Expert 05/2013 05/2014 Company Name – City State · Worked contracted claims expert Excellus BCBS NY · Responsible claims processing HOME Commercial, Medicare Medicaid plans · Processed claims HOST side plan updating provider files credentials support claims adjustment. · Worked special projects assigned management. Provider Claims Service Unit Representative I 03/2008 11/2012 Company Name – City State · Responsible immediate responses incoming provider calls regarding claims issues. · Process incoming correspondence providers claims issues need resolved Passport Health (Medicaid) Passport Advantage. · Reprocessing claims identified incoming phone calls submitted provider relations staff. · Identifying systematic procedural issues resulting claims processing errors initiating action resolve issues. · Documenting calls, problems, resolutions future reference · Proficient Microsoft Word, Excel, Power point, Outlook, Internet Explorer, Facets, IKA Systems, CMS Pricers, DRG Calculator, ICD-9, CPT, Basic Office Systems web application · Worked special projects assigned management Benefits Plan Administration/ Eligibility Enrollment/Client Service Expert 05/2004 03/2008 Company Name – City State · Answered incoming calls regarding eligibility, claims processing, billing inquires. · Administered employee group benefits retirees, active, long term disability, cobra participants · Resolved Issues billing, carrier eligibility, etc. · Organized special projects web inquiry responses, updating accurate information knowledge base customer service tool assigned management · Team lead/ Initiated training full-time temporary associates ongoing call center open enrollment. Customer Service Claims Specialist-Chicago Medicare/ Commercial/ Medicaid 04/2001 02/2003 Company Name – City State · Supported Chicago Medicare Medicaid Commercial Markets · Received inbound outbound calls insured members, clients, brokers, agents providers · Mailed related correspondence enrollment material, forms brochures members. · Processed medical claims needed adjustment · Knowledgeable DRG, ICD-9, CPT coding Managed customer calls effectively efficiently complex, fast-paced challenging call center environment. Accurately documented, researched resolved customer service issues. Managed high call volume tact professionalism. Acted professionally patiently addressing negative customer feedback. Resolved service, pricing technical problems customers asking clear specific questions. Effectively managed high-volume inbound outbound customer calls. Claims Examiner 07/2014 05/2015 Company Name – City State · Worked Claims Examiner client Kaiser Permanente Southern California. · Responsible data processing incoming Hospital UB's Medicare/ KPSA Plan. · Contract interpretation validate proper payment logic claim adjudication. · Identify billing coding errors submit documentation provider's necessary corrected claims forms sent Medicare compliance guidelines. · Adjudicate Replacement Bill Type Late charge claims etc. accordingly per client's guidelines processing. Proficient Microsoft Word Excel, Power point, Outlook, Internet Explorer, CMS Pricers, DRG Calculator, ICD-9, CPT, Basic Office Systems variousweb applications Precisely completed appropriate claims paperwork, documentation system entry. Thoroughly researched newly identified diagnoses and/or medical procedures expand skills knowledge. Resourcefully used various coding books, procedure manuals on-line encoders. Actively maintained current working knowledge CPT ICD-9 coding principles, government regulation, protocols third party requirements regarding billing. Education Bachelor Science Psychology Current Liberty University City State Psychology/ Christian Counseling Administration Advocacy Case Management Community Relations Counseling Mental Health Services Programming Certification 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