Customer Service Quality Assurance

LYNETTE S. WRIGHT

**** ******** ****

Home 717-***-****

Cell 717-***-****

QUALIFICATIONS SUMMARY:

Healthcare insurance professional with a strong professional background that encompasses fourteen years

of experience in senior provider relations, provider contracting and recruitment, contract negotiations,

customer service, claims processing, configuration testing, quality assurance, provider education,

authorizations, medical terminology, procedure and ICD-9 coding.

Areas of Expertise

Processing Systems Claims Related Software

AMISYS CMS 1500’s Windows

STREAMLINE EDI’s Excel

FACETS UB92’s Access

MACESS CPT codes Word

TINGELY HCPCS codes PowerPoint

BlueZone/MC400

PROFESSIONAL EXPERIENCE:

March 2008 to present Gateway Health Plan, Pittsburgh, PA 15219

Provider Relation Representative (telecommuter)

• Serve as the primary liaison between Gateway Health Plan and the central Pennsylvania and surrounding

areas.

• Build and maintain strong relationship with providers by offering excellent customer service to assigned

primary care, ob/gyn and specialty care physicians.

• Conduct on-site visits, telephonic and written communications with individuals including Hospital CEOs

and CFO’s, Patient Account Managers, Physicians and Billing Managers.

• Conduct Environmental Assessments and group orientations.

• Work independently as a telecommuter and attend off site meetings, including overnight stays.

Feb 2007 to March 2008 AmeriHealth Mercy Health Plan, Harrisburg, PA 17111

Provider Contracting Representative

• Responsible for recruiting healthcare providers and educating existing healthcare providers regarding the

Medicaid HMO plan process or changes.

• Perform site visits, new provider orientations and face to face contract negotiations with par and non

participating healthcare providers, while also reviewing Medicaid and Medicare fee schedules.

• Prepare contract amendments while maintaining positive relationships with healthcare providers.

• Review healthcare provider appeals and work to resolve claim payment issues.

• Travel as well as working remotely,

• Assist outreach marketing representatives regarding member complaints and coordinating community

events.

• Facilitate monthly phone meetings with healthcare providers regarding service issues and performing

research and analysis to identify root causes.

Lynette S. Wright’s Page 2

Feb 2006 to Feb 2007 Pennsylvania Employee Benefit Trust Fund Harrisburg,, PA 17111

Internal Staff Auditor

• Responsible for reviewing paper and electronic claims from various Medicare intermediaries.

• Interview various employees and health insurance product lines regarding departmental procedures.

• Perform audits against negotiated contracts; testing to ensure all areas of the contracts is operating

affectively. Audit financial invoice statements of payments made to various health insurance product lines.

• Facilitate conference agenda’s explaining our audit objectives and methodology, also preparing written

summaries regarding audits preformed, including findings and recommendations for improving various

departmental procedures.

Dec 2004 to Nov 2005 AMERIGROUP Corporation, (Medicaid HMO) Virginia Beach, VA 23464

Configuration Testing Analyst-Business Systems

• Responsible for reviewing incoming Amisys System configuration requests to ensure that all pertinent files,

forms and information are received.

• Responsible for testing Amisys System configuration for new provider/facility contracts, contract

amendments and project configuration received from Reimbursement Configuration department.

• Testing and reviewing of the following Amisys configuration components in pricing: payclass(es), pay

service qualifiers, keywords, counters, fee schedules, codes and code sets.

• Testing configuration of providers and ancillary claims while following business rules.

• Provided accurate error condition reporting to Reimbursement Configuration regarding errors found during

Amisys testing and review stages.

• Review configuration by matching configuration in the production environment.

• Create test plans, test logs and test cases to configuration in the production environment.

Dec. 2002 to Dec 2004 AMERIGROUP Corporation, (Medicaid HMO) Virginia Beach, VA 23464

Quality Assurance Specialist

• Audited a minimum of 5% of all claims entered into the system by each claims analyst.

• Responsible for quality checking various Medicaid market products.

• Responsible for auditing a minimum of 25% up to 100% of all claims entered by each probationary

analyst.

• Prepared reports of each audit and forwarded copies of the results to the analysts.

• Responsible for quality checking of pended claims/compliance reports worked by claim analysts,

coordination of benefits and third party liability analyst.

• Researched all coordination of benefits and third party liability procedures.

• Applied necessary adjustments and refund requests on overpayments.

• Maintained a daily log of claims production reports generated by AMISYS.

• Audited Provider Affiliation Configuration Associates under all Medicaid markets.

• Documented and reported all errors found into the departmental database.

• Managed monthly quality reports for provider configuration and credentialing teams.

• Quality checked and sorted vision and pharmacy rosters.

• Practiced provider affiliation and credentialing policies and procedures

Lynette S. Wright’s Page 3

Aug. 2001 to April 2002 Synertech Corporation, Harrisburg, Pennsylvania 17109

Customer Service Representative

• Performed financial adjustments to overpayments and under payments of claims.

• Researched and adjusted claims in suspense status.

• Calculated special pricing of claims.

• Reviewed prior authorizations to make payments on inpatient and outpatient claims.

• Quality checked payment edits for negative claim balances.

• Initiated check voids and refund requests.

• Processed out-of-area claims and RF’s.

Feb. 2000 to Aug. 2001 HealthCentral Inc. Harrisburg, Pennsylvania 17109

Provider Inquiry Claims Coordinator (Company went out-of-business)

• Accountable for resolving issues raised by providers regarding claim payments.

• Performed adjustments on claims with results from providers and/or other sources.

• Researched and resolved pending claims, denials and overpayments.

• Communicated daily with providers via telephone as appropriate.

• Processed an average of 80-100 claims.

• Processed third party liability (TPL) and coordination of benefit claims (COB).

Feb. 1999 to Jan 2000 Pennsylvania Physicians Care Harrisburg, Pennsylvania 17109

Senior Customer Solutions Representative (Company went out-of-business)

• Processed and made payment adjustments to claims.

• Documented incoming calls into an inquiry database.

• Conducted benefit training for new employees.

• Quality checked all outgoing correspondence

• Supervised and mentored telephone representatives.

• Assisted clients regarding policies, procedures and membership eligibility.

EDUCATION:

Sept 1990 to Jan 1992 Thompson Institute Campus Harrisburg, Pennsylvania 17109

Associates Degree in Business Technology

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