sr provider network specialist resume example with 7+ years of experience
JessicaClaire
, , 100 Montgomery St. 10th Floor(555) 432-1000, resumesample@example.com
Summary
Currently in process of CPC certification exam with completion of CPC training with AAPC. I understand the importance of confidentiality and the change that healthcare industry brings. I am dependable, holds over 8 years of experience in the healthcare operations industry. When in question I will research before asking team members or management. Communicates with outstanding planning, interpretation and organizational skills. Detail-oriented, hardworking and committed to taking initiative. Always willing to jump in and help where needed. 3 years working remote with little supervision. Manages several clients and resolves request and issues in a timely manner. Meets daily goals and assignments while helping other teams when needed.
Skills
Confidentiality with discretion
In the process obtaining my CPC certification with AAPC and completion of training.
Organizational Skills
Provider Network, Configuration, and Implementation
Coordination of Benefits training cert-10/19/14
Advanced Analyst training cert-08/12/15
Proficient in Excel, Microsoft applications
SQL knowledge
Quick to learn and remember.
Love to research, reach and obtain short and long term goals
I am a team player always happy and willing to help when and where needed.
Honest, hard working and proficent
Experience
03/2022 to CurrentSr Provider Network SpecialistCentene Corporation | Kapolei, HI,
Proofread contracts and W9 documents carefully to check accuracy and completeness of all paperwork.
Maintains positive working relationship with staff and management.
Sets up provider and vendor records per Medicaid and Medicare guidelines with appropriate fee schedules per contracts and locality.
Follow up with clients' to address and rectify denied and pending claims.
Conversed with people from different cultures, providing high level of respect and patience with each interaction.
Maintains confidential patient documentation to prevent data compromise and comply with HIPAA regulations.
Answers and responded to inquiries to deliver high level of service.
Responds to requests for information for providers to be set up correct in a timely manner.
12/2021 to 03/2022Provider Network SpecialistModern Technology Solutions, Inc. | Los Angeles, CA,
Enhanced client satisfaction ratings by resolving claims and clarify issues.
Investigates concerns such as billing and claims questions on behalf of clients.
Maintained professional relationships with all levels of service.
Instruct clients on procedures and policies. Strong relationships to maintain provider network knowledge and implement each client accordingly.
Interpreted contractual agreements and guidelines for contracted and non contracted providers to accurate set up on provider and vendor records.
Participates in audit processes to ensure quality management accreditation.
Eliminated contractual risks by instructing clients and educational material distribution from CMS and Medicaid websites.
Stayed current on available policies and plans.
02/2020 to 01/2021Claims Management/Medical Claims AnalystTabula Rasa Healthcare | City, STATE,
Streamlined day-to-day office processes to meet daily and long-term goals.
Located and retrieved files, contracts, guidelines and general information. Manually priced, adjusted claims per contract, and Medicare, Medicaid fee schedules by locality. Built authorized authorizations per clients guidelines. Created reports for clients prechecks to send for payment approval.
Obtained necessary information to complete proper evaluation of outstanding claims. Communicated with clients to obtain claim information and documentation for processing. Implemented process for several clients, provider education areas. Reviewed medical records, medical bills and authorizations to determine claims payment.
Reviewed policies to determine and assist with approval or denial decisions. Investigated and analyzed requirements to improve timeliness of pend reports, discussed current cases and issues in claim committee meetings.
Followed all company procedures to keep data confidential.
Reviewed administrative guidelines whenever questions arose, or changes made for processing of claims.
06/2014 to 01/2020Advanced AnalystCentene Corporation | City, STATE,
Reviews documents to verify compliant policies and procedures for claims processing.
Handled billing related activities focused on medical specialties.
Used insurance rate standards to calculate premiums, refunds, commissions and adjustments.
Assisted new employees with processing claims.
Retained strong medical terminology understanding in effort to better comprehend procedures.
Administered standard contract benefits to process pending claims for dental benefits.
Examined claims, records and procedures to grant approval of coverage.
Tracked differences between plans to correctly determine eligibility and assess claims against benefits and data entry requirements.
Called insurance companies to ascertain pertinent information regarding policies and payment benefits for patients.
Handled modification and updating of policies.
Sent clinical request and missing information letters to obtain incomplete information.
Accurately processed large volume of medical claims every shift.
Based payment or denials of medical claims upon well-established criteria for claims processing.
Assisted claimants, providers and clients with problems or questions regarding claims.
Checked documentation for appropriate coding, catching errors and making revisions.
Used contract notes and processing manual to correctly apply group-specific classifications to claims.
Signed payment approvals accepted claims.
Evaluated pending claims to identify and resolve problems blocking auto-adjudication.
Reviewed administrative guidelines whenever questions arose during processing of claims.
Collaborated with fellow team members to manage large volume of claims.
Organized information by using spreadsheets, databases or word processing applications.
Precisely calculated refunds, premiums and adjustments.
Processed claims for payment or forwarded to appropriate personnel for further investigation
Stayed current on HIPAA regulations, benefits claims processing, medical terminology and other procedures.
Drafted reports of loss to summarize payments, underlying policy coverages and denials.
Modified and updated existing policies and claims to reflect change of guidelines.
Prepared and reviewed insurance-claim forms and related documents for completeness.
Transcribed data to worksheets and entered data into computer to prepare documents and adjust accounts. Sent to Macros for batch processing so a large number of claims could be released.
Documented file notes clearly and concisely in system.
Education and Training
Expected in 05/2013 to to Associate of Applied Science | Office Systems Technology-Medical CodingMineral Area College, Park Hills, MOGPA:
Expected in 05/2013 to to Associate of Applied Science | Administrative Assistance And Secretarial ScienceMineral Area College, Park Hills, MOGPA:
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