RESUME OF KARMEN COLES

Karmen Coles **** Brookfield Square South Columbus, OH 43229 614-***-****

ad10sa@r.postjobfree.com

HEALTHSCOPE Benefits January 21, 2019 June 7, 2019 Customer Care Representative

Provided Customer Service for members and providers answered member benefit questions related to Medical, Dental and Vision Benefits. Understand and able to read benefits providing member deductibles, copays and Out of pocket related to medical, dental and vision benefits worked many different benefits plans able to Understand each plan assigned to. Working in a call center setting heavy phone calls from providers Hospitals, Doctor Office, labs and members to provide benefits information and how a claim processed. Handled all call backs for surgery, denial of Claims and following up on denied claims and researched to see it the claims were processed according to member Benefits. Assist members to getting benefits reinstated when benefits were cancelled Maintained a call back folder and followed up On the scheduled dates for return calls. Called hospital billing to address balance billing patient (member) able to get providers to write off bills if claim was not billed according to the member benefits. Working claims as well dealing with hospital billing department and doctor office billing staff for claims that were submitted with incorrect location, diagnosis codes or CPT Codes also address claims that denied due to CPT Codes submitted with incorrect modifier or no modifier at all. Meeting TAT and meeting production Buckeye Community Health Plan March 2015 – May 2018 Senior Customer Representative III

Worked as Senior Customer Representative III supporting Senior level Leadership ability to handle confidential information appropriately; in the provider inbound and outbound call center department working heavy call volume department which require to meet Quality standards and TAT status understanding of Medicare and Medicaid contracts and guidelines. Understanding member insurance benefits for Medicare and Medicaid also the provider contracts. Received calls from biller of Hospitals, Lab, Durable Medical Equipment, Doctors office calling for claim status on inpatient hospital admission, inpatient surgery and outpatient surgery and medical equipment claims working appeal status on denied claims provided appeal information and able to give the correct timely filing for an appeal or a claim pertaining to if the provider was in network or out of network. Working department that handled Medicare & Medicaid insurance for patient which require highly sensitive HIPPA rules and regulations worked claims for members who had Medicare and Medicaid coverage which required the ability and review a claim and tell a provider why the claim denied or paid understanding of ICD9 and ICD10 codes as well as CPT code billing able to read a hospital UB92 and 1500 claim form understand and explain to the provider how their claim processed according to their contract and the billing codes the provider submit their claims understanding of explaining to the provider and break down a claim by service location and ICD9 or ICD10 codes and CPT codes related to the service billed. Provided excellent customer service skills which gave me the opportunity to handle supervisor calls for co-workers who were unable to control their call with a provider and unable to explain how a claim was process or denied was able to explain in detail to the provider how they claim process and quickly defuse irate call to the supervisor. Handled very large hospital bills which required a call to the hospital biller to break down how a one hundred dollar to one hundred thousand dollar claim was process paid or denied. Worked negative balance claims were the provider owed Buckeye Health Plan money this was a 30 days process to find the negative balance claim which required great math skills and claim knowledge once the negative balance was found faxed over to the biller so they could close their month end books submit their payment to Buckeye. Work provider calls claim denial and how a claim paid by their contracts. Selected to train new hires once they came out of the training room to the floor I was selected to do side by training for the new hire they sat with me for two weeks then went to their own desk on a daily basis I answered department questions for the customer service team and received many rewards for outstanding customer service also was the top QA customer service rep on my team each month only came in 2nd three times during my time in this department in the Ambetter department for I was selected by my team to receive the department reward for outstanding customer service which required myself and other staff from other departments that met the same standard to be selected for a CEO and Manager meeting and got the reward for myself and my team. Progressive Medical Inc., Westerville, OH June 2007 - May 2013 Client Service Specialist III

Worked as Workmen Compensation Biller related to contract with Liberty Mutual Insurance Company received incoming calls and conduct follow up phone calls with patients, medical facilities, insurance companies, employers. Workmen Compensations Adjuster and Attorney offices.Processed medication claims related to patient injuries which were approved by the Adjuster. Made high volume of calls to Pharmacies to get the medication processed through the "RESTAT Pharmacy" system and data enter all claims. Verified with Adjuster all medication approval related to work injuries. Monitored patient medical progress and needs during length of care. Understood drug codes, formulary and had the ability to read medical prescriptions. Made calls to Workmen Compensation Adjuster by phone or email to send correct system processing action to get the medication approved following all workmen Compensation laws, rules and regulations. Made calls to patients regarding benefits and advised on medications that have been approved or denied by their Adjuster.

Promoted to the UMWA (United Mine Workers of America) department ordered Durable Medical Equipment, wheelchairs, hospital beds, CPM machines, power scooters, walkers also ordered diapers, diabetic supplies and wound supplies. Made phone calls to doctor's office to request the prescription for the equipment and supplies understanding the diagnosis code related to the equipment or supplies which-will retrieve the approval from the UMWA Review Nurse who reviews for Medical Necessity. Ordered some supplies and some equipment using a medical order-catalog Made Inbound and outbound calls to Vendors and patient to coordinate delivery time for the equipment or supplies.Followed HIPPA Laws when speaking with the patient's family or outside sources who may not have the patient’s approval to speak on the patient’s behalf. Met department production standards of 95% by maintaining QA scores 95%-100% data entry of all orders and other clerical duties..

American Health Holding Inc., Worthington, OH November 2002 - June 2007 Intake Coordinator/Customer Service Representative

•Answered phones to input demographics and clinical charting for inpatient and outpatient recertification for surgery Knowledge of ICD9 coding, CPT coding and HCPC coding to be able to data enter clinical Handled calls and questions from Third Party Administrators, Doctors office and patients. Handle customer complaints and concerns, researching cases to give to the appropriate information to patients, doctors and Hospitals educate patient on Pre-certification requirements for surgery and hospital inpatient stay, referred patients, doctors and hospitals to verify benefits. Worked appeal cases with the contact person within the benefits office, working (COB) Coordination of Benefits with Medicare and other insurance companies. Working the call back list for discharge dates when patient discharge from the Hospital.

• Requested clinical documentation related to the surgery to forward to the Case Manager faxed and forward report requested by the Case Manager working in a high pace and high volume department which required meeting production standards and turnaround times.

• Sat with new employee after training using headsets to listen to live calls related to scheduled surgery, inpatient hospital stay and other medical request.