Diamond Kittles

Expert in ALL MICROSOFT Software

Newport News, VA 23602

ad48t4@r.postjobfree.com

+1-757-***-****

To obtain and secure a position that will enable me to use my quick learning and organizational skills passionately while applying enthusiasm and professionalism for healthcare and customer service with a thorough approach as a member and leader of a professional team. Willing to relocate to: North Carolina - Texas - Georgia Authorized to work in the US for any employer

Work Experience

Claims Adjuster

Exela Technologies (Sentara Optima Health) - Irving, TX October 2022 to February 2024

• Communicate with insurance agents and beneficiaries to retrieve clarification of benefits.

• Preparing claim forms and related documentation.

• Reviewing claim submissions and verifying the information.

• Recording and maintaining insurance policy and claims information in a database system.

• Reviewing payment requests for services that have already been performed to verify that the service was provided and that the charges were reasonable.

• Determining policy coverage and calculating claim amounts based on Medicaid or Medicare.

• Processing claim payments.

• Complying with federal, state, and company regulations and policies.

• Process reconsiderations for providers who re-bill a claim with different HCPC, DX codes or modifiers

• Update provider profiles, such as medical practice addresses, payment information, and certification

• Update information such as member ID or DOB in order for claims to successfully process.

• Process a workload of a minimum of 160 claims daily

• Attend trainings and meetings to stay updated on work policies and procedures.

• Attach Explanation of Benefits (EOB) to claim to calculate payments.

• Performing other clerical tasks, as required.

• Create spreadsheets with member information and concern about claims to receive proper assistance for adjudication.

• Accept and complete claim audits within duration provided for quality assurance purposes Enrollment Specialist (Healthcare)

Papa Inc. (Family on Demand) - Miami, FL

November 2021 to January 2022

• Managing high call volume from outbound phone traffic

• Engaging with customers, listening and uncovering their needs while making recommendations and maximizing revenue for Papa

• Conducting a proactive, consultative needs analysis on new and existing customers while also identifying and including the development of customer-centric product solutions

• Provide education to all members about products, services, and scheduling details

• Provide the highest level of customer service while hitting benchmarks and converting incoming calls into a scheduled visit

• Handling and conducting phone duties in a timely and professional manner in accordance with company policies and procedures

• Achieving member engagement standards set for the department by following the established departmental policies and procedures

• Serve as a virtual companion to those who may just want to talk about their current situation, day, or may actually be in need of scheduling services.

• Demonstrating a full understanding of current campaigns and offerings while communicating them clearly to customers at every sales opportunity

• Responding to customer complaints in a professional manner and attempting to resolve objections in accordance with established guidelines

• Provide or refer crisis assistance to members who request or seem to be experiencing trauma.

• Multitasking and operating several applications along with proficiency in G-Suite

• The ability to operate in a fast-paced environment taking back to back calls or making phone calls

• Possessing excellent verbal and written communication skills Claims Processor

Lockheed Martin - Newport News, VA

November 2020 to April 2021

The Claims Processing team is responsible for processing a variety of benefit transactions such as pension packages, payment elections, beneficiary changes, tax changes, flexible spending account claim reimbursements, etc. for the participants of our clients.

• Review images of paperwork from benefits plan participants, utilizing all resources, procedures, and critical-thinking skills to determine eligibility for request and submit electronic transactions according to client and client/plan specific rules and IRS regulations and guidelines.

• Must be able to work in a fast paced environment with multiple transactions on a daily basis

• Process all DME requests and Verify Medical Necessity documentation

• Activities include:

• Electronic document preparation and indexing into case management system.

• Review and research document images of returned mail to determine validity of address. Notate and flag participant’s account if determination is made that address is no longer valid.

• Mail & correspond to mailed images & documents by sorting requests for appeals, new applications, and paper filed claims for processing

• Electronically attach correspond documents to client’s claims for faster processing method

• Determine if requested transaction meets plan eligibility rules, as well as, IRS regulations and guidelines.

• Understand “gray areas” of IRS guidelines, effectively applying these guidelines to each case processed.

• Review legal guardianship, conservatorship and power of attorney records if transaction is requested by a party other than the participant to determine if that party is authorized to request the specific transaction.

• Review paperwork for completeness and accuracy, including completion of all required fields and notarization, if required, and inclusion of legal documents such as birth certificate copies. Paperwork can be 30 pages or more, especially pension packages.

• Calculate eligible reimbursement based on available funds, requested amount, requested reimbursement, previous reimbursements and substantiated documentation.

• Review history of requests, transactions, and call notes to determine if prior transactions disqualify the request, if previously incomplete paperwork is now complete, or if other exception conditions exist

• Paperwork such as pension packages often require submission of multiple transactions, such as setting up beneficiary elections, direct deposit elections, as well as whether the pension will be distributed in a lump sum or periodic payment, or combination of the two.

• Maintain and update case management system notes.

• Follow-up on open items daily and close cases upon completion. Cases can remain open for days, weeks or months if initial paperwork is incomplete, or requires an exception determination or future event is pending.

• Collaborate with other internal departments and third-party vendor to obtain exception processing information and address participant or client escalations.

• May be tasked with peer review on work completed by other peers. Overnight Dispatcher/Customer Service Representative Hampton Veterans Hospital - Hampton, VA

January 2020 to October 2020

• Answer switchboard, transfer, and place calls to necessary staff throughout the health facility to ensure physicians and nurses can work efficiently as a team to treat patients and all of their needs to its entirety.

• Utilize paging systems to notify physicians and nurses that their services are needed in other locations.

• Participate in reading code blue machines & giving assurance that all equipment is working properly

• Use in-house spreadsheets to notify callers who's on call for the day/night of interest & adhere to contact preference.

• Dispatch 911 for emergencies on site, and if needed by veterans

• Respond to Veterans inquiries regarding appointments, hospital updates, directions, and COVID-19 testing sites.

• Follow script guidelines to provide World Class Service to all patrons needing service from the facility.

• Work together with physicians to build a schedule for on call doctors per each shift to ensure smooth transitioning for appointments, codes & emergency visits.

• Fill out work orders for emergent and non emergent maintenance calls and dispatch an on call worker for assignment based on level of need.

• Utilize patient roster to update & transfer family members to current in-house veterans' whereabouts in the facility; charge nurses and patient rooms.

• Call code pager to ensure all pagers & other equipment are prepared for each shift and working.

• Log information pertinent to codes to make sure I'd follow up is needed, it could be done successfully and accurately.

• Assist customers with a warm and professional attitude

• Kept records of customer complaints and concerns

• Schedule or reschedule meetings and appointments for veterans in need of appointments or other assistance

• Assist with technical support duties regarding office supplies and materials. Claims Processor (Healthcare)

Wisconsin Physicians Service's Humana TRICARE DIVISION - Hampton, VA August 2017 to December 2018

• Receive healthcare and insurance based telephone, written, fax, and e-mail inquiries concerning eligibility, benefits determinations, and claims adjudication questions or billing problems of Tricare Beneficiaries.

• Dispute and sometimes reprocess claims that need adjustment.

• Reach out to billing physicians directly for select patients who need to discuss payment options and financial grievance ie. (fixed incomes, etc)

• Applies appropriate provisions of regulations, interpretations, and procedural directives in making determinations on eligibility and benefits to determine appropriate responses to inquiries.

• Obtains and analyze claims data to determine specific problem areas including external communication to obtain data.

• Receive calls for referrals and authorizations transactions, review, upload documents, and modify authorizations/referrals as prescribed by physicians for select patients for claim processing.

• Request/provide medical records to/from physicians and patients for specific needs to assist with adjudication of claims process.

• Verify patient demographic status, contact information, insurance eligibility, OHI, PCP changes, and provide guidance through the claims filing process as well as provide explanation of benefits (EOB)

• Complete research and provide final resolution to inquiries within contractual requirements.

• Thoroughly view medical records and medical necessity documentation to determine eligibility for approval.

• Communicate with inquirer to determine appropriate authorization or referral of services.

• Utilize Claims systems for research & documentation

• Maintain professionalism and abide by all HIPAA laws while handling customers information

• Verify HCPC codes are payable by Tricare Humana before guaranteeing payment to providers to ensure accuracy on all claims filed.

• Confirm payment method and amounts for claims paid and billed back to Tricare Humana for reimbursement

• Process DME claims based off of Medical Necessity documentation or authorization forms.

• Educate providers on billing requirements to reduce claim deficiencies.

• Follows through with each issue to resolution by working with internal and external resources as needed

• Deal tactfully with people in a wide variety of situations to convey a favorable corporate image by resolving urgent and high-profile problems from Beneficiary Counseling, Billing Physicians, Assistance Coordinators & Beneficiaries who bill their own claims.

• Respond to inquirers using various forms of communication (written letter, telephone, web, or email) within time frames to exceed contractual standards.

• Obtains revenue by recording and updating financial information; recording and collecting patient charges; controlling credit extended to patients; filing, collecting, and expediting third-party claims

• Understand which claim form to use when keying in claims.

• Verify HCPCS Codes for eligibility of payment according to Tricare Policies and payment guidelines

• Receive inquiries and register patient and client reports on lost payments and file stop payments as necessary to eliminate theft.

• Confirm other health insurance and get specific information for those injured in LOD (Line of Duty)

• Input data entry correspondence into system, diaries information for claims reps and/or team leader, and prepares forms.

Call Center Team Lead (UPS)

EGS Call Center - Newport News, VA

July 2016 to May 2017

• Speak to customers over the phone, email, online chat or social media to resolve their questions or concerns.

• Calmly attempt to resolve and de-escalate any issues the client may have concerning shipping accounts and claims

• Take Escalated supervisor calls when necessary and appropriate in lieu of supervisor not being available

• Responded to requests for assistance and/or possible processing credit card authorizations

• Determine the most effective resolution to all customer service issues while maintaining confidentiality of customer's accounts

• Respond to inquiries regarding package location, discuss tracking details to put customer's mind at ease.

• Schedule package interceptions should the sender decide they want it back or the receiver decides they no longer need it.

• Determine eligibility for reimbursement depending on damage and cause of damage on merchandise by scheduling inspections in person or online via email.

• Provide retention management to clients who threaten to close account due to unsatisfaction

• Make outbound calls to dispute claims with account holders, discuss packaging guidelines and account summaries.

• Input damage details into system (multiple systems)

• Verify Declared Value or (insurance) on packages

• Hold quarterly performance meetings with members on the team to discuss metrics, and call quality

• Monitor calls to ensure quality requirements are being met

• Tracked call-related information for auditing and reporting purposes

• Provides feedback reports on call issues related to downtime and/or training issues

• Enter data regarding unsatisfied business (damaged packages) reports in corporate system

• Schedule lost package investigations & provide electronic updates to customers

• Determine if claims decision should be upheld or overturned based off of packaging guidelines & provide packaging counseling to ensure quality is always at its best with merchandise Telecommunications Operator

Riverside Health System - Newport News, VA

December 2014 to July 2016

Provided information regarding hospital office hours, visiting hours, directions, scheduling and patient information to visitors and patients while maintaining and complying with HIPPA laws

• Possessed the knowledge of medical coding to assist with internal system procedures

• Receive, transfer, and place outbound calls to all departments in each facility

• Maintain accuracy and organization for all patient records

• Provided proficient clerical duties as needed while operating multi-lined telephone system

• Answer emergency code phones to receive notification of type of code, physical demographics, and condition of patient

• Utilize overhead in the main hospital to announce code or locate physicians and team

• Fill out code log to keep record of all emergencies every 24 hours

• Contact Security team in case of disruption or emergencies

• Display knowledge of HIPAA Laws and regulations by observing all patient confidentiality

• Contact physicians directly after hours for their specialty patients in case of emergency followed with warm transfers

• Submit prescription request and refills to physicians mail boxes

• Provide empathetic and compassionate responses and assistance to family members grieving over hurt or loss of family

• Utilize office equipment such as fax, printer

• Contact emergency officials (911) when caller is in a state of panic or is suicidal

• Provide assistance and coach callers through emergency situations while waiting for police to arrive Education

HIGH SCHOOL DIPLOMA

MENCHVILLE HIGH SCHOOL

June 2011

Skills

• 9 years+ of customer service and relationship management

• Motivated hard worker with positive attitude and strong attention to detail

• Proficient using technology including Windows operating systems and Microsoft Office applications

• Awarded Phone Pro Certificate for utilizing my knowledge, critical thinking and soft skills on the job

• In possession of Government Interim Status Security Clearance

• Benefits administration

• Documentation review

• Live Chat

• Medical Coding

• Multi-line Phone Systems

• Auditing

• Medical Billing

• Insurance Verification

• HIPAA

• Medical Scheduling

• Help Desk

• ICD-10

• Employee Orientation

• EMR Systems

• Customer Relationship Management

• Hospital Experience

• Microsoft Outlook

• CPT Coding

• Medical Records

• ICD-9

• Epic

• Technical Support

• Laboratory Experience

• Telecommunication

• Triage

• Quality Assurance

• Medical Office Experience

• Accounting

• Medical Terminology

• Anatomy Knowledge

• Recruiting

• Microsoft Excel

• Customer service

• Typing

• Computer networking

• Contracts

• CRM software

• Sales

• Medical collection

• Zendesk

• Customer support

• Google Suite

• Contracts

• Medicare

• EDI

• PCR

• iOS

• Master data management

• Communication skills

• Microsoft Office

• Process improvement

• Research

• Windows

• Computer skills

• Organizational skills

• Clerical experience

• Typing

• HIPAA

• Hospital experience

• Cash handling

• Telemarketing

• Windows

• ICD-10

• ICD-9

• Live chat

• Medical coding

• Software troubleshooting

• Data collection

• Google Suite

• Customer relationship management

• Telecommunication

• Remote access software

• Cold calling

• Help desk

• Google Docs

• Mobile devices

• Conflict management

• Technical support

• Epic

• Relationship management

• Human resources

• Recruiting

• Research

• Quality assurance

• Customer service

• Dispatching

• Accounts receivable

• CRM software

• Problem management

• Social media management

Certifications and Licenses

Driver's License

Assessments

Call center customer service — Completed

September 2021

Demonstrating customer service skills in a call center setting Full results: Completed

Work motivation — Proficient

October 2020

Level of motivation and discipline applied toward work Full results: Proficient

Indeed Assessments provides skills tests that are not indicative of a license or certification, or continued development in any professional field.

Contact this candidate