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Work Content Specialist/ Claims Rework Unit Resume Example

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WORK CONTENT SPECIALIST/ CLAIMS REWORK UNIT
Executive Summary

A very detail-oriented person who enjoys problems-solving, analyzing data, and developing a solution. I have excellent leadership and communication skills. Hard working and reliable and able to collaborate in a team endeavor. Enthusiastic individual who is willing to learn and excel in a competitive and challenging environment. Vast knowledge of Medicare Claims processing, Billing and Enrollment, Pharmacy Claims, Collections, and Customer Service. Ability to type 95+ wpm. Maintain inquires at a low level to provide the best perfect service possible. Currently fluent in the following Microsoft Programs: Excel, Word, PowerPoint, Outlook, and Share point. In addition working knowledge in the following Humana specific systems: CCP, SinglePoint, CAS, MTV, CIS, CISPRO, PAAG, Mentor, Knowledge Source, ClaimsXten, Macess, Argus, Letter Generator, Marx, and Litton.

Core Qualifications
  • Complex problem solving
  • Calm under pressure
  • Skilled negotiator
  • Time management
  • Supervision and training
  • Inventory control
  • Team player
  • Team leadership
Professional Experience
Humana March 2011 to May 2014 Work Content Specialist/ Claims Rework Unit
Louisville, KY
  • Researched, reviewed, and reprocessed Medicare member claims
  • Set up financial recoveries on overpaid claims
  • Assisted in the development of training documents on department processes
  • Assisted in development of associates by acting as a SME (service matter expert)
  • Oversaw the Medicaid tank to control aging
  • Handled escalated issues
  • Able to research and work independently, with great time management skills
Humana May 2013 to Current Account Concierge Specialist / Provider Concierge Unit
Louisville, KY
  • Performed root cause analysis to resolve complex Market escalations and escalated provider disputes
  • Identified trends, variances, and opportunities for provider education
  • Achieved relationship building with external partners and providers by attending on site and teleconference meetings
  • Acted as a liaison between the Market representative and the provider
  • Assisted with technical questions for the market and peers
  • Worked closely with the Process Improvement Team, facilitating training huddles on new processes and process changes
  • Research, document, and analyze multi-faceted data with statistical, financial, and clinical emphases to determine a root cause analysis
  • Identify data trends and assist in presenting and implementing recommendations and solutions
  • Work closely with operation areas to develop future enhancements of the systems as well as system support for any defect resolution
  • Maintain and apply expert and current knowledge of contracts, benefits plans, and claims
Humana October 2008 to March 2011 Customer Service Specialist/ Individual Medicare and Group Medicare
Louisville, KY
  • Assisted and educated Medicare members and providers with enrollment, eligibility, pharmacy, claims questions, and Humana's products and services over the telephone
  • Quoted benefits
  • Participated in special projects
  • Served as a SME (service matter expert)
  • Assisted with training classes by serving as a SME (service matter expert)
  • Handled high call volumes on a daily basis
  • Performed overrides and coordination of benefits authorizations
  • Participated on numerous outbound call campaigns and projects
Light Year Network Solutions July 2007 to March 2008 Representative Support
Louisville, KY
  • Assisted customer with repair problems with their phones
  • Assisted Lightyear Sales Representatives with customer service issues
  • Input applications into the system along with data entry
  • Called on rejected applications to resolve any clerical errors and answered billing questions
  • Took inbound and made outbound phone calls to resolve issues with customers
Brown Jordan International May 2006 to April 2007 Customer Relations Specialist
Louisville, KY
  • Contact on point of sale for all cash orders and warranty issues on patio furniture
  • Ensured proper booking for replacement product
  • Answered all escalated warranty calls to ensure resolution
  • Contact shipping departments on all order discrepancies
  • Resolution of shipping issues and orders
Citi Cards March 2004 to October 2005 Collection Specialist
Louisville, KY
  • Made outbound phone calls to delinquent Sears cardholders
  • Requested payment and sold Sears products and services for existing cardholders
  • Set up payment arrangements
  • Skipped tracing and exceeded collections requirements each month
Providian Financial September 1999 to January 2004 Senior Collections Specialist/ Team Lead
Louisiville, KY
  • Took inbound/outbound phone calls from delinquent Providian cardholders
  • Collected 100,000 or more on a monthly basis and handled escalated phone calls
  • Coordinate activities within the department to ensure they are supportive of organizational goals
  • Provided quality customer service regarding complaints and escalated issues
  • Assisted supervisors with team member performance reviews
  • Assisted representative in performance issues such as how to obtain goals
  • Provide technical support to associates and peers
  • Awarded Top collector multiple times
  • Review and respond to quality audits and maintain quality goals
Education
Indiana University Elementary Education Bloomington, IN

Attended this University for 2 years with a major of General Study. I am in the process of enrolling at Columbia Southern University to complete my bachelor degree in Business Management.
Affiliations
  • PCU Engagement committee
  • LSC Well Being Wizard
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Resume Overview

Companies Worked For:

  • Humana
  • Light Year Network Solutions
  • Brown Jordan International
  • Citi Cards
  • Providian Financial

School Attended

  • Indiana University

Job Titles Held:

  • Work Content Specialist/ Claims Rework Unit
  • Account Concierge Specialist / Provider Concierge Unit
  • Customer Service Specialist/ Individual Medicare and Group Medicare
  • Representative Support
  • Customer Relations Specialist
  • Collection Specialist
  • Senior Collections Specialist/ Team Lead

Degrees

  • Elementary Education

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