Customer Service Medical

Aspirations: Top performing professional with over 10 years of increasingly

responsible experience focus towards providing a positive relationship

between facility and client while insuring optimal operation compliance and

performance.

EXPERIENCE

Senior Claims Analyst Level 4

Montefiore (CMO)

06/05- Present

Specializing in Behavioral Claims, Special Handling Unit

. Organize, support, and assist examiners with assignments, monitor work

flow

. Oversee payments of health insurance claims and maintain accuracy of

information on checks to providers.

. 216 claim pends processed daily while maintaining 98% correct

accuracy.

. Analyze claims are paid, pending, or denied according procedures.

. Maintain Audit report of electronically submitted claims.

. Evaluate CPT/ICD-9/HCPCS code submission for validity, rebundling,

unbundling, and covered/non-covered services.

. Assist management with weekly check reimbursement process, and

systematic auditing of Explanation of benefits (E.O.B).

. Receive work assignments, view policy changes, collaborate with other

depts., verify and explain the continuity of CQI audits.

. Recoup money from health plans on claims that are overpaid. Adjustment

of underpaid claims for correct payments.

. Worked with Implementing of benefits, and rates to various templates.

. Achieved departmental goals by performing at a high level of

performance resulting in three promotions within my tenure.

. Experienced working with Behavioral Claims, UBA UB92 and UBA HCFA

Claims.

. Worked with Special Handling Unit, Trouble shooting various

adjustments to rectify proper payment to the Providers and health

insurances

Claims Analyst,

Managed, Cigna healthcare Account

03/01 - 06/02

Montefiore (CMO)

. Managed and ran account for Cigna, handled all processes of claims

dealing with CIGNA health plan

. Priced claims according to Medicare fee schedule manually priced and

adjusted claims for proper payment.

. Processed claims within a timely fashion to guarantee contractual

agreement with Cigna.

. Kept Cigna claims organized in separate draw where access to Cigna

claims was secured.

Service Representative

Olsten Staffing Service

06/99 - 10/99

. Field corporate clients and other Customer Service issues

. Routine secretarial and clerical duties.

. Data entry for account maintenance and billing.

Processor, AccuStaff Temps

Site at U.S. Trust Co., New York

11/97 - 10/98

. Administrative accounting for Corporate Trust Operations.

. Monitor Medical Staff Database in computerized credential system.

. Complete Fund Transfers and balancing of Checking Accounts.

Data Analyst, (Contingent)

Montefiore Medical Center, Bronx, New York

01/94 - 01/97

. Monitor Medical Staff database in computerized credential system.

. Process and verify physician's files. (Data bank, DOH, HHS)

. Audit Physicians' files per NCQA and Montefiore Standards.

EDUCATION AND TRAINING

Mercy College

School of Masters Business Program in Business/Management

08/11

NY State Health Adjuster/Accident & Health

01/03

License # IA-524152

Typing (65wpm), Microsoft office works, Access, Cross training with Finance

Dept. within CMO, Financial software (SAP), IDX system, Intelliclaim,

GroupWise, Qnxt software, Alchemy, Dar web software, and Core care

management system - CCMS. Extensive knowledge of working with Medicare and

Medicaid Team oriented professional eager and willing to lead and work

collaboratively with colleagues to successfully achieve goals and

expectations.

REFERENCE UPON REQUEST

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