Customer Service High School
Resume:
San Antonio, TX *****
Cell: 210-***-****
*************@*****.***
Steve Martinez
Objective
To obtain a position as a Claims Examiner with the opportunity of
advancement..
Experience
University Health System/Community First Health Plans
December 2008- Current Member Services/Claims Examiner
San Antonio, TX
This positions responsibility includes taking incoming calls from
Community First providers inquiring on payment status on their claims
submitted. Doing so requires the knowledge and the understanding of medical
billing and procedures. My knowledge includes working with HCFA 1500/UB-04
claim forms, processing/adjudicating claims when needed, reviewing provider
contracts and determining if claims paid accordingly, understanding and
working with diagnosis codes, CPT codes, HCPC codes, Revenue Codes,
modifiers etc. I also review the claims to make sure everything falls
within the provider's contract and/or guidelines that need to be followed.
This position also requires extensive knowledge of the government-funded
programs such as the CHIP (Children's Health Insurance Program) and
Medicaid program.
University Health System/Community First Health Plans
April 2008- November 2008 Member Services
San Antonio, TX
This positions responsibility includes taking incoming calls from
Community First HMO, PPO, Medicaid and CHIP members; assisting them with
questions they may have in regards to their health plan, including claims,
PCP changes and current eligibility. I also assist members on bills they
may have received from a provider by doing extensive research, and
examining the medical claim thoroughly to determine why the member is
getting billed for the particular type of service. This involves
identifying denials and understanding denial codes/diagnosis codes to
determine if the type of service the member had is a covered benefit based
on the member's policy. Then once determined whether the claim will be paid
or not paid, I will follow up with the member in a timely manor explaining
to them the outcome. If the member is requesting an EOB (Explanation of
Benefit) or EOP (Explanation of Payment) to be mailed, I will print one and
mail it to the member. I also take incoming calls from Provider's offices
and Hospitals wanting to verify eligibility, benefits, deductible status,
member co-pays and responsibility, or if Authorization is required for
services they will render to a member. They also have me assisting in
training our new employees now, making sure they understand thoroughly on
how our health plan works before they are on their own. This includes
providing evaluations to management on their improvements daily.
Accounting Principles/ Community First Health Plans
November 2007- April 2008 Member
Services San
Antonio, TX
This position responsibility includes taking incoming calls from
Community First HMO, PPO, Medicaid and CHIP members; assisting them with
questions they may have in regards to their health plan, including claims,
PCP changes and current eligibility. I also assist members on bills they
may have received from a provider by doing extensive research, and
examining the medical claim thoroughly to determine why the member is
getting billed for the particular type of service. This involves
identifying denials and understanding denial codes/diagnosis codes to
determine if the type of service the member had is a covered benefit based
on the member's policy. Then once determined whether the claim will be paid
or not paid, I will follow up with the member in a timely manor explaining
to them the outcome. If the member is requesting an EOB (Explanation of
Benefit) or EOP (Explanation of Payment) to be mailed, I will print one and
mail it to the member. I also take incoming calls from Provider's offices
and Hospitals wanting to verify eligibility, benefits, deductible status,
member co-pays and responsibility, or if Authorization is required for
services they will render to a member.
Caremark Rx Inc.
June 2005 - August 2006 Customer Service
Rep. / Senior Team San Antonio, TX
Position responsibilities included answering calls from
members/providers, assisting with their questions regarding their
prescription coverage, taking refill orders, assisting retail pharmacies',
and assisting Doctors offices with patient benefit coverage. I was also
promoted to work with resolution manager team. Duties included going over
the tasks that were submitted in error by our Customer Service
Representatives and correcting them according the participants plan and
company policy. This included analyzing claims and adjusting them according
to the member's policy based on the issue, involving extensive research and
consulting with Caremark Account Managers, Pharmacy Techs, and Pharmacist.
Then once we determine how the claim should be paid, we will contact the
participant to inform them what action we are going to take to satisfy what
was requested. I also assisted our senior team by helping with
escalated/help calls that our customer service representatives had by
providing my extensive knowledge on the product to assure a solution to the
issue at hand.
Education High School Diploma
San Antonio, Tx
Southwest High School Graduated in May 2003
References
Available upon request
Contact this candidate