remote claims representative resume example with 9+ years of experience
Jessica
Claire
resumesample@example.com
(555) 432-1000,
, , 100 Montgomery St. 10th Floor
:
Summary
Committed job seeker with a history of meeting company needs with consistent and organized practices. Skilled in working under pressure and adapting to new situations and challenges to best enhance the organizational brand.
Skills
HIPAA compliant, Texas Medicaid Programs CMS
Medical Billing Processing
Insurance Billing
Epic Systems
ADP
Training & Development
Medical Terminology
Behavioral Health
Leadership Experience
Leadership Training
Meeting Planning
Internal Audits
Interviewing
ICD Coding
Quality Assurance
Auditing
Employee Evaluation
Medical Office Experience
Patient Data Abstracts
Insurance Verification
Management
Clerical experience
Anatomy Knowledge
Therapy
Data Entry
Conflict Resolution Techniques
Verbal and Written Communication
Call Center Operations
Positive and Constructive Feedback
Education and Training
South University, Expected in 06/2020 ā āMBA: - GPA:
Argosy University, Expected in 06/2016 ā āBachelor of Business Administration: - GPA:
Experience
Lake Region Healthcare Corp. - Remote Claims Representative Elbow Lake, MN, 04/2022 - 07/2022
Modified and updated existing policies and claims to reflect change in beneficiary, amount of coverage or type of insurance.
Provided quality customer service to assigned, insured and claimants throughout claims process to deliver timely service to customers.
Retained strong medical terminology understanding in effort to better comprehend procedures.
Handled billing related activities focused on medical specialties.
Transcribed data to worksheets and entered data into computer to prepare documents and adjust accounts.
Organized information by using spreadsheets, databases or word processing applications.
Coordinated and planned investigations of claims to confirm compensability and coverage.
Submitted claims to insurance companies and researched and resolved denials and explanations of benefit rejections.
Performed accurate and fully compliant monthly closing processes, accruals and journal entries.
Provided prompt and accurate services through knowledge of government regulations, health benefits and healthcare terminology.
Contacted insurance providers to verify insurance information and obtain billing authorization.
Monitored past due accounts and pursued collections on outstanding invoices.
Answered customer invoice questions and resolved issues discovered during invoicing and collection process.
Prepared and posted weekly payments to vendors and suppliers.
SELECTQUOTE - Remote AEP Customer Care Representative City, STATE, 07/2019 - 10/2019
Delivered fast, friendly and knowledgeable service for routine questions and service complaints.
Built sustainable relationships and trust with customer accounts through open and interactive communication.
Maintained high satisfaction score by consistently resolving first-call issues.
Interacted with customers to provide and process information in response to inquiries, concerns and requests about services and products.
Provided feedback on customer service efficiency to deliver better support options.
Documented customer correspondence in CRM to track requests, problems and solutions.
Kept customer and system account information accurate and current to support timely resolutions for concerns.
Centene, Superior Health Services - Behavioral Health Referral Specialist Supervisor of Call Center City, STATE, 03/2018 - 06/2019
Supervised day to day activities of the Referral Services department including: interviewing, hiring, and training employees; planning, assigning, and directing work; evaluating performance; rewarding and disciplining employees; addressing complaints and resolving problems
Assisted providers, members and/or internal customers with cases pertaining to referral questions, issues and prior authorizations
Reconciled pended claim issues in a timely manner per health plan/department procedure
Reviewed and processed denial letters, maintained logs, and coordinated decisions to external or internal personnel per plan procedures
Received and reviewed incoming phone and case management log reports and determined course of action
Worked with analysts and programmers in adapting and testing programs and procedures to adhere to our standard operating procedure
Created step by step work process
Familiarized with Policy and procedures
Oversaw day to day operations of the team, distributed the workload evenly amongst staff and maintained motivation and performance levels
Answered members and providers questions and gave information regarding the business procedures and policies in an exact and customer-friendly
Prepared monthly audits, quarterly, and annual reports for therapy log to ensure compliance with the process and turn-around timeframe (TAT) for all markets notification
Processed authorizations using CPT codes and ICD9 and ICD10
Reviewed Medicaid and Medicare of members
Assisted different Health plans with Behavioral process/request
Assisted with psych evaluation request
Centene, Superior Health Services - STRS Referral Specialist Supervisor City, STATE, 06/2016 - 06/2019
Supervised day to day activities of the Referral Services department including: interviewing, hiring, and training employees; planning, assigning, and directing work; evaluating performance; rewarding and disciplining employees; addressing complaints and resolving problems
Assisted providers, members and/or internal customers with cases pertaining to referral questions, issues and prior authorizations
Reconciled pended claim issues in a timely manner per health plan/department procedure
Reviewed and processed denial letters, maintain logs, and coordinated decisions to external or internal personnel per plan procedures
Received and reviewed incoming phone and case management log reports and determined course of action
Worked with analysts and programmers in adapting and testing programs and procedures to adhere to our standard operating procedure
Created step by step work process
Familiarized with Policy and procedures
Oversaw day to day operations of the team, distributed the workload evenly amongst staff and maintain motivation and performance levels
Answered members and providers questions and gave information regarding the business procedures and policies in an exact and customer-friendly
Prepared monthly audits, quarterly, and annual reports for therapy log to ensure compliance with the process and turn-around timeframe (TAT) for all markets notification
Processed authorizations using CPT codes and ICD9 and ICD10
Reviewed Medicaid and Medicare of members
Assisted different Health plans with STRS process
Reviewed Audits
Centene, Superior Health Services - Team Lead/Denial Coordinator City, STATE, 05/2013 - 06/2016
Attended, participated and set up weekly and monthly team meetings
Oversaw the Medical Management denial process including letter printing, tracking and disposition of letters within contractual guidelines to ensure compliance
Monitored all CMS Avaya Claims call queues to ensure service level expectations are met as contractually outlined
Served as the department liaison and trainer for all denial and/or appeals issues
Acted as a resource for other staff
Proved ability to answer members and providers questions and give information regarding the business procedures and policies in an exact and customer-friendly
Implemented new initiatives and making sure all staff understand them
Prepared monthly audits, quarterly, and annual reports for denials and/or appeal log to ensure compliance with the denial process and turn-around timeframe (TAT) for all denial and/or appeals notification
Reviewed and processed denial letters, maintain logs, and coordinated decisions to external or internal personnel per plan procedures
Centene, Superior Health Services - Referral Specialist City, STATE, 02/2013 - 05/2013
Assisted in monitoring utilization of medical services to assure cost effective use of medical resources through processing prior authorizations
Initiated authorization requests for outpatient and inpatient services in accordance with the prior authorization list
Routed to appropriate staff when needed
Verified eligibility and benefits
Answered phone queues and process faxes within established standards
Entered authorizations into the system
Trained others on authorizations and/or faxed work processes
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Resume Overview
School Attended
South University
Argosy University
Job Titles Held:
Remote Claims Representative
Patient Access Specialist
Remote Coding Specialist
Remote Billing Specialist
Remote AEP Customer Care Representative
Behavioral Health Referral Specialist Supervisor of Call Center