Livecareer-Resume
Jessica
Claire
resumesample@example.com
(555) 432-1000,
Montgomery Street, San Francisco, CA 94105
:
Summary

Seasoned health care professional with over 10 years experience in positions ranging from customer service, claims processing, benefit analyst, to modeling contracts, quality assurance and managing vendors. Provide thorough and skillful support to senior management. Also willing and able to learn new tasks.

Skills
  • Product testing
  • Data analysis
  • Process implementation
  • Methodology implementation
  • File and records maintenance
  • Updating computer records
  • Confidential records
Education and Training
Bronx Community College of The City University of New York The Bronx, NY Expected in 01/2013 Associate of Arts : Human Services - GPA :

The AAS curriculum prepares students for employment as mental health aides, group residence workers, neighborhood outreach workers, social case work assistants, geriatric counselors, assistant probation officers and other similar positions. Employment opportunities exist in such areas as day care, mental health, social services, aging, rehabilitation of the disabled, group and community work at the public and private level.

Experience
Legalshield - Administrative Assistant (Vital Records)
Seattle, WA, 11/2019 - Current
  • Assists customers in the completion of application for certified copies of vital events.
  • Screens applications for necessary information and entitlement to documents.
  • Issues certified copies of vital records.
  • Advises when discrepancies are apparent on original documents or when no record is found.
  • Enters data from application into electronic avail records system.
  • Follows established policies regarding security paper and collection and receipting of fees.
  • Reconciles any discrepancies to ensure strict accountability for audit purposes.
  • Create amendments by affidavits of correction. paternity acknowledgments, legitimation, and court orders as well as delayed birth certificates.
  • Assists in a variety of assigned clerical and office maintenance duties including but not limited to filing, organizing, and answer telephone calls.
  • Close out cash drawers at the end of the day to ensure accuracy of monetary transactions.
Anthem, Inc. - Provider Contract Modeler
Flowood, MS, 10/2016 - 01/2018
  • Designed, built, and validated successful transmission of client managed cared contracts and in client company contract management systems (EPIC Resolute HB (training), PCON, STAR, PIC), Full Cycle Implementation.
  • Generated daily reports from the various contract management systems to review accounts/claims and identify contractual underpayments for collection of lost revenue.
  • Managed projects, created work flows, organized departmental guidelines/tools and trained new analyst on specific systems.
  • Audited contract models, rates for revenue integrity to ensure accurate revenue generation.
  • Interpreted contract reimbursement, rate validation, and provided support to client and company.
  • Developed strong working relationships with the assigned client and team members to ensure the consistent and efficient flow of communication in acting as one of the client's main points of contact.
  • Utilized knowledge of payor reimbursement methodologies.

EmblemHealth - Vendor Relations Manager
City, STATE, 04/2015 - 09/2016
  • Acted as a liaison between vendors/clients and various internal departments such as; Case Management, Quality, Delegation, Grievance and Appeals, and more.
  • Coordinated and hosted bi-weekly and or contracted monthly meetings with vendors to review/discuss reports, finances or any issues and concerns.
  • Processed monthly invoices for each vendor and its program to ensure timely/correct payments.
  • Maintained internal/external mailbox and respond to inquiries within timeframe.
  • Ensured policies, memos, and or guidelines were current with the clients and uploaded in Emblem Health's database for all departments to view as needed.
  • Utilized eSaws and QCare systems to view member's benefit information. Researched, analyzed and entered claims submitted by hospitals or patients.
  • Kept track of the audit process from each client and to ensure all clients were abiding by Emblem Health's standards from Legal, IT, Diseased Management, Security and a few more areas.


EmblemHealth - Provider Contract Specialist, Sr
City, STATE, 07/2007 - 04/2015
  • Reviewed all negotiated contracts for accuracy prior to implementation into production and recommend or enhance development prior to loading.
  • Researched and analyzed reasons for claims which were pending and determined a resolution as issues related to facility contracts and system configurations.
  • Tested claims and manipulated provider rate files in prototype to resolve issues and provide problem solving analysis.
  • Loaded rates, CPT/HCPC codes, revenue codes, DRG codes, target services for Mainframe to ensure correct payments for claims.
  • Assisted in contract auditing as needed.
  • Created and updated training manuals for union and managerial personnel.
  • Served as a liaison to aid in claim review, rate interpretation and system abilities to other departments.
  • Communicated with negotiators when language and or rates were not compatible with Mainframe's capabilities.
  • Obtained documents, clearances, certificates and approvals from local, state and federal agencies.
  • Provided training to new employees/consultants when needed.

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Resume Overview

School Attended

  • Bronx Community College of The City University of New York

Job Titles Held:

  • Administrative Assistant (Vital Records)
  • Provider Contract Modeler
  • Vendor Relations Manager
  • Provider Contract Specialist, Sr

Degrees

  • Associate of Arts

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