Worker Comp Administrator Monday Friday 40 Hr Wk resume example

● Responsible for daily management of account receivable process and follow up in the billing system, including daily screening and correction of claims for accuracy for the surgical department
● Review, correct and completion of edit queues weekly for the particular insurance (s) assigned for the surgical department
● Follow-up on pending claims, this includes following up with the insurance company, document the findings and gather and send the necessary documentation to process the claims.
● Responsible for the appeals process, which included researching payer websites, pulling of documentation such as EOB's, requesting medical records, and reviewing registration/eligibility and benefits, as well as documenting all work performed on the patient invoice.
● Customer Service calls. Responsible for handling customer service calls and demonstrate excellent customer service skills, listening, problem solving, professionalism, etc
● Handle confidential information with accordance with HIPAA standards.
● Conducts forensic accounting on account balances that have been open for over a year or more by reviewing invoices history to determine payments/retractions and inform management of discoveries for swift resolution
● Provide Management with analytical data and trend analysis that occur within insurance carriers

● Processed medical referrals in a timely manner to include but not limited to completion of service request (direct and prior authorization referrals) forms manually and/or through EMR

● Faxed service requests to Utilization Management department for approvals

● Processed and send requests to the specialty offices for processing and scheduling of patient appointment

● Notified patients of scheduled appointments by phone, in person with appointment information or by mail and documented in the patients chart

● Obtained insurance information from patients, which included collecting co-payments and self-paid balances from patients

● Followed up with specialist offices on pending/outstanding patient appointments and documented in patients chart

● Processed consult reports that were received, completed and close referrals in the patient's charts

● Reported referral problems to providers, supervisor and administrator

● Reviewed referral log daily and provided weekly progress to supervisor and administrator

● Worked closely with outside vendors to establish and build effective working relations

● Worked closely with Utilization Management, Provider Services and Contracting Department

● Single-handily managed, worked, maintained, and closed a two year backlog of the clinic's referrals, denials and authorizations within the first year of employment

● Familiar with Medicare Advantage plans

● Provided call coaching, constructive feedback and direction to staff to ensure consistent customer service

● Demonstrated mastery of customer service call script within specified time frames

● Provided technical expertise to staff and handled elevated calls

● Explained training methods and teaching skills sufficient to conduct continuing education for staff development.

● Monitor overall quality, education, completeness and accuracy of medical record documentation

● Explained coding and documentation concepts, guidelines, and clinical terminology

● Ability to establish and maintain strong verbal and written communication with providers

● Conducted monthly audits on staff to ensure quality of care and customer service is giving

● Responded and resolved members inquires, complaints, included incoming calls from outside Medicare state department inquiring about policy and procedures, concerns of benefits as well as claims discrepancies ● Possess understanding of call center metrics and best practices to achieve optimal performance

● Monitor Finesse and communicated with Work Force Management to improve agent productivity