Insurance Customer Service
Resume:
PHILIP E. STERLING, CPC
Orange, CA 92868
************@*********.***
PROFESSIONAL SKILLS
Working knowledge of ICD-9, CPT, HCPCS, revenue, & procedure codes
used with physician, and hospital insurance submissions using NextGen,
Office Ally, EZCap, AS400, Epic, Medical Manager, IDX, Allscripts,
eBridge, Capario, HMS, Xifin 5.5 (Mars), Microsoft Word & Excel
PROFESSIONAL MEDICAL INSURANCE EXPERIENCE
Contracted Positions (thru agencies, and self employed), Orange County CA
8-10 to Present
Coder/Biller/Collector/Patient Account Representative/Programming
Consultant(WGTK)
. Assigned ICD-9 codes to lab claims for insurance submission for
LabWest, & Phoenix Medical.
. Contacted providers by phone, website or fax for coding/procedure
clarification.
Contracted Positions (thru agencies, and self employed), Louisville KY
10-09 to 4-10
Patient Account Specialist/Auditor/Medical Coder
Responsible for reviewing several aging reports such as non-payment
EOBs, no response claims, and denials. This included contacting
insurance payers to check claims status by phone or website, and
rebilling corrected physician claims in a production environment.
. Left Louisville to relocate to Orange County, CA.
(CHOC) Children's Hospital of Orange County, Orange CA
5-09 to 10-09
Patient Account Representative/Pediatric Billing
Responsible for working several aging reports such as non-payment
EOBs, no response claims, and denials. This included contacting
insurance payers to check claims status by phone or website, and
rebilling corrected Endocrinology physician claims in a production
environment.
. Worked within CalOptima/CCS/Medi-Cal guidelines, and commercial
carriers.
Received calls from patients regarding their accounts, updated
insurance information, retrieved medical records, and assisted other
departments as required. Physicians verified the accuracy of medical
claims submitted to the insurance carriers for clarification.
. Recorded, and edited training modules for the Human Resources
Department.
. Left CHOC Hospital to temporarily relocate for family reasons.
Tristar Insurance Group, Santa Ana CA
2-07 to 3-09
Sr. Technical Claims Specialist/Sr. Technical Billing Analyst/Coder II
Reviewed, verified and coded workers' compensation physician,
hospital, legal/QME insurance injury claims and prescription invoices
for final adjudication.
. Audited re-submitted provider bills to assure additional payment could
be approved.
. Handled high dollar and complex liability injury claims for physical
pain and related costs.
. Worked with managers at all levels in production meetings,
streamlining the payment processes.
. Left TriStar because of the lack of work, and the decline of the
economy.
Contracted Positions (thru agencies, and self employed), Orange County CA
6-04 to 2-07
Claims Resolution Specialist/Coder/Biller/Collector/Auditor/Patient Account
Representative
. Investigated medical claims over 60 days from weekly A/R report.
. Researched, corrected and re-filed claims that were denied by
insurance.
. Posted primary EOBs and Medicare/Medicaid remit payments.
. Handled billing calls from patients, insurance carriers, and patient
representatives.
. Verified and corrected patient information for accurate claims re-
submission.
. Contacted patients regarding their accounts, offering payment balance
options.
. The positions ended because the individual company contracts had been
completed.
Humana Health Insurance, Louisville KY
2-91 to 5-04
Medical Claims Resolution Specialist/Trainer/Examiner and Analyst/Claims
Verifier/Coder
. Processed HMO, commercial, Medicare HMO, and Medicare Supplemental
policy insurance claims on both HCFA, and UB92s in a production
environment.
. Resolved quality control issues by correcting billing errors on
submitted physician and hospital claims in the Medicare, and Medicare
HMO units.
. Initiated calls to providers, regarding on-going billing errors and
worked together to resolve claims issues for clearer accuracy and
faster payment processing.
. Assisted the call center on in-bound calls regarding claims payment
issues from contracted providers, and commercial/Medicare supplemental
insurance members.
. Worked with managers and supervisors to implement and improve training
programs.
. Co-taught Claims Examiner/Adjuster classes and created classroom
material for each class. Developed and taught classroom materials to
assist in preparing the newly hired claims examiners/adjusters and
customer service associates after training.
. Gathered evidence for on-going fraud investigations on selected
providers.
. Voiced surgery and claims training videos for distribution to all
educational centers.
. Left Humana to relocate to Orange County, California
CREDENTIALS AND EDUCATION
American Academy of Professional Coders (AAPC) Member/PHIA Certified 2-2010
Passed the California Bill Review state exam for reviewing and processing,
HCFA,
and hospital workers compensation insurance claims, June 2007 with a 93%
score.
Monash University, Caulfield VIC Australia 3145, B.A. Business
Administration 11-1982
Jefferson Community College, Louisville KY Major: Business Administration
April 2004
Santa Ana Community College, Santa Ana CA, Journalism/Liberal Arts Major
CIVIC FUNCTIONS
Channel Islands Restoration Project, Santa Cruz Island Project, Ventura CA
volunteer 2007-2008
The Nature Conservancy, Santa Cruz Island Project, Santa Barbara County CA
volunteer 2008-2010
SUMMARY
AAPC Member
Supervisory experience
Effective communication skills
PHIA Certified Coding Professional
Classroom and one-on-one trainer/educator
20 years in the medical health insurance field
Responsible, team oriented, analytical problem solver
Strong background in government and commercial claims processing
Contact this candidate