Customer Service Representative

Healthcare Claims Tiffany Patterson

Consultant & Customer 1107 Hutton Street, 2nd Floor ( Troy, NY 12180 ( (518)

and Provider Care 892-8503 ( *************@*******.***

Specialist-Call Center Customer Care and Provider Specialist - Identify and anticipate

customer needs through proven customer interaction techniques to

ensure customers a positive experience in sometimes challenging

Professional Objective circumstances. Examples of support were provided in the following

instances:

Verify Member Benefit Information

Dedicated and Resolve Claims Processing Issues

commitment to Resolve Billing and Membership Inquiries

excellence through Claims Consultant - Utilizing Facets, Macess, Max MC and various

claim resolution and other systems

helping providers Adjudicate all medical, mental and dental claim types

resolve issues. Interpret Provider Contracts ensuring correct benefits are applied

Recognizes, utilizes, to claims

and identifies Adjust Claims to Correct Processing Errors and Provider errors.

potential problems and Experienced in all commercial lines of business including ASO

finds solutions. (self funded) FEP, Medicare, Medicaid, Mental Health, and Dental

products for both professional and facilities.

Professional Skills

Experienced in

processing and Jacobson Solutions Chicago IL

interpretation of Claims Consultant - Blue Cross Blue Shield of LA

claims in all lines of 09/2010 to Present

commercial business Assist in the determination of goals with teams, clients, and

and ASO (Self-funded), project management.

Medicare, Medicaid, Investigate, document, resolve and settle all assigned claims to

Dental, FEP, Mental the satisfaction of the client and company.

Health, TPA's, IPA's Assisted in testing Facets for production procedures for inpatient

and Reinsurance Medicare and Professional Medicare Coordination of Benefit claims.

products. HIPPA

compliant.

MVP Health Care Schenectady, NY

Efficiently assists Provider Claims Representative/ Claims Analyst

customers with 09/2007 to 01/2010

inquiries regarding Analyze and Process all claim types utilizing Facets, Macess, Max

the following MC and various other software (Professional, Outpatient and

utilizing various Inpatient Claim types).

systems including Investigated possible fraudulent claims and recommended litigation

Facets, various when appropriate.

version: Assisted with special reports including recoveries and recoupment

Claims Adjudication projects; resolve complex claims-processing issues, and claim

Claims Adjusting status updates via incoming phone calls from providers and

Claims Interpretation hospitals.

Benefits Maintained quality standards of 99% accuracy and above.

Pre Authorization,

Pre- Determination, Express Scripts, Troy NY

and Pre- Certification 10/2005-7/2007

Customer Service Representative

Coordination of

Benefits

Provider Network Answer inquiries from members, doctors and pharmacist in reference

Pricing to eligibility, claims status and benefit information via phone,

Member Eligibility fax and mail Maintained quality standards of 99% accuracy and

. above.

Research and document all outbound and inbound calls.

Education Represent the organization daily though customer contact and

7/2006-Present relationship-building.

Strayer University

Online Great Lakes Health Plan and Cape Health Plan Southfield MI

BA of Arts 02/2002-12/2005

Business Management Claims Processor/Analyst

Adjudication and adjusting of all claims types.

Status claims for Provider Services and Quality department.

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