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Client Relations Facilitator Resume Example

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JC
Jessica Claire
, , 100 Montgomery St. 10th Floor (555) 432-1000, resumesample@example.com
Summary

Personable, friendly and solution-oriented Client Relations Professional with over 15 years of experience in service and support. Customer-focused team player offering expertise in conflict mediation, time management and organization. Dedicated to customer loyalty and satisfaction.

Skills
  • Phone
  • Administrative, Websites
  • CMS, Written
  • Clients
  • Customer Service
  • Diagnosis
  • Documentation
  • Edit
  • Financial
  • Forms
  • General office
  • Insurance
  • Inventory
  • Letters
  • Excel spreadsheets
  • Mail
  • Organizing
  • Policies
  • Procedure development
  • Processes
  • Publications
  • Quality
  • Quality assurance
  • Quality Management
  • Quality improvement
  • Read policies
  • Record keeping
  • Reporting
  • Risk Management
  • Telephone
  • Courteous demeanor
  • Problem-solving abilities
  • Technologically savvy
  • Microsoft Office expertise
  • Insurance regulations knowledge
  • Report creation
  • Clerical support
  • Project management abilities
  • Quality assurance controls
Experience
09/2015 to Current Client Relations Facilitator Lhc Group | Dry Fork, VA,
  • Responsible for the quality assurance of clinical reviews by reviewing cases completed by the physician consultants.
  • Ensure the turnaround times are met with a quality review.
  • Draw on a wide range of clinical expertise to edit/provide credible case narratives in response to client questions.
  • Communicate with clients and expert reviewers, as necessary to track reviews.
  • Follow-up with client for input/clarification concerning the case review.
  • Perform and maintain accurate computer case records.
  • Act as a Liaison between the Physician/Allied Health Reviews; Account Managers and Customer Service Representatives to ensure the daily operations are client-specific.
  • Participate in the continuous quality improvement (CQI) process by identifying and reporting quality issues as established by existing protocol.
  • Work with management to oversee, monitor and improve quality of services provided in all business lines including participation in policy and procedure development of the case review program.
  • Participate in the training of new and existing staff as assigned by management.
  • Investigated technical issues using knowledge base and personal experience to complete timely resolutions.
04/2015 to 09/2015 Risk Management Support Specialist Erie Insurance | Canton, OH,
  • Risk Management.
  • Perform general office functions such as daily mail distribution, required copying, and management of paper and electronic administrative records.
  • Read and analyze incoming memos, submissions, mail and reports to determine significance; plan distribution.
  • Maintains and administers all risk management information on excel spreadsheets and online CRM tools.
  • Assist in obtaining product information directly from vendors, vendor websites, or other healthcare resources.
  • Responsible for organizing invoices and drug screen results for workers compensation claims.
  • Assists with new Client implementation including preparing claim reporting packets, labor posters and certificates of insurance.
  • Coordinate policy and procedure documents, including formatting and coordinating review for approval.
  • Collaborated with colleagues in Risk Management in the development of publications, completion of guidelines, policies, and forms while ensuring proper format and grammar.
  • Create and distribute Certificates of Insurance for workers compensation insurance coverage.
  • Assists in workers compensation underwriting submission process.
  • Verified reports for completeness to conform with established regulations and procedures.
11/2013 to 06/2014 Life Claims Examiner MassMutual | City, STATE,
  • Mass Mutual (CFS) USIG - Life and Disability.
  • Provided timely, balanced and accurate claim reviews and documentation, and recommended decisions in a time sensitive, fast-paced environment.
  • Compiled file documentation and correspondence requiring extensive policy and factual detail.
  • Identified information and resources needed to adjudicate claim.
  • Communicated decisions to policyholders in verbal and written form.
  • Conducted lengthy, detailed information-gathering phone calls to obtain medical condition and financial details, along with other pertinent information.
  • Referred to external and internal resources, such as physicians, attorneys and accounting staff to gather data such as medical information in order to ensure well-reasoned decisions.
  • Maintained and reported all compliance, grievance and appeal data including member files, logs, reports, documentation and tracking information in a consistent & approved format.
  • Paid and processed claims within designated authority level.
  • Investigated questionable claims to determine payment authorization.
03/2013 to 10/2013 Medical Appeals Analyst Broadpath Healthcare Solutions | City, STATE,
  • Reviewed member appeals and provider claim disputes and conducted investigations and completion of responses within given timeframes.
  • Referred quality of care complaints to Quality Management for resolution.
  • Assisted Quality Management in investigation of medical reviews as appropriate.
  • Examined member files and provider claim or billing discrepancies.
  • Coordinated with claims department in order to successfully achieve corrective actions and resolutions.
  • Maintained and reported all compliance, grievance and appeal data including member files, logs, reports, and documentation and tracking information in a consistent, approved format.
  • Interpreted medical policies and other legal documents.
  • Generated written correspondence to customers such as members, providers, and regulatory agencies.
  • Performed daily audit on Medicare pending claims for resolution.
10/2012 to 03/2013 Audit Administrator Kelly Services | City, STATE,
  • Created written correspondence for the development of CMS audit recovery packets.
  • Audited letters and other written correspondence.
  • Initiated probe requests for estimated overpayment refund calculations.
  • Reviewed and researched local and national medical policies for recovery packet development.
  • Uploaded pertinent files to the company’s website for inventory and record keeping purposes.
  • Maintained and reported all compliance, grievance and appeal data including member files, logs, reports, and documentation and tracking information in a consistent, approved format.
  • Formulated, implemented, and executed all processes, requests, and policies as requested by management in a courteous and efficient manner.
  • Calculated potential recovery amount of overpayment based on diagnosis codes and maximum units allowed.
12/2008 to 12/2010 VIP Medicare Claims Specialist ConnectiCare | City, STATE,
  • Adjusted claims in accordance with the most current policy benefits, limitations or exclusions through an automated work queue.
  • Coordinated with physicians, hospitals and internal staff to gather information required resolving complex claims issues.
  • Investigated and adjusted Coordination of Benefits claims by applying appropriate guidelines.
  • Summarized and presented essential information for the Clinical Specialist, Medical Director and legal counsel for successful resolution of claims.
  • Ensured appropriate resolution to inquiries and appeals within specified deadlines.
  • Interpreted medical policies and other legal documents.
  • Generated written correspondence to customers such as members, providers, and regulatory agencies.
  • Performed daily audit on Medicare team’s written correspondence.
12/2002 to 12/2007 Medicare Appeals Analyst First Coast Service Options | City, STATE,
  • Performed telephone adjustment requests by medical providers.
  • Researched local and national medical review policies.
  • Corrected and adjusted medical codes.
  • Evaluated and performed adjustments on medical appeal requests.
  • Identified potential overpayment and fraud.
  • Interpreted medical plan legal documents.
  • Maintained policies to ensure compliance with CMS regulations.
  • Updated team with workflow changes.
  • Created new Standard Operation Procedures.
  • Updated department workflow manuals.
  • Demonstrated leadership by making improvements to work processes and helping to train others.
  • Prioritized and organized tasks to efficiently accomplish service goals.
Education and Training
Expected in BA Degree | Psychology Central Connecticut State University, New Britain, CT, GPA:
Expected in AS Degree | Liberal Arts Capital Community Technical College, Hartford, CT, GPA:
Expected in AS Degree & Certification /Multimedia & Web Design | Middlesex Community College, Middletown, CT, GPA:
Certifications
  • Code of Conduct
  • Systems Security Awareness and Compliance
  • Raising and Resolving Ethical Issues
  • Creative Problem Solving
  • ISO 9001: 2000 Project Certification
  • Freedom of Information Act Certification

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Resume Overview

School Attended
  • Central Connecticut State University
  • Capital Community Technical College
  • Middlesex Community College
Job Titles Held:
  • Client Relations Facilitator
  • Risk Management Support Specialist
  • Life Claims Examiner
  • Medical Appeals Analyst
  • Audit Administrator
  • VIP Medicare Claims Specialist
  • Medicare Appeals Analyst
Degrees
  • BA Degree
  • AS Degree
  • AS Degree & Certification /Multimedia & Web Design