•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 in support 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 support claims 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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