•Office support (phones, faxing, filing)
•Excellent verbal communication
·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
·Responsible for duties insupport of 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
·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
·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.
·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
·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 supportclaims adjustment.
·Worked any other special projects as assigned by management.
·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
·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.
·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
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