Medical Customer Service

Apexya Patel, LPN

*********@*****.***

Cell# 732-***-**** Home# 732-***-****

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Summary

. Knowledgeable in technology and health care.

. Skilled in troubleshooting and maintenance of technical equipment.

. Maintained high quality standards with an emphasis on accuracy within

strict guidelines.

. Ability to handle multiple tasks and work efficiently.

. Ability to established and maintains effective working relationships

and interact with all colleagues

. Capable of working independently, possess excellent verbal and written

communication.

. Demonstrated ability to build rapport and resolve complex issues among

multiple entities with conflicting interests.

. Extensive customer service background.

. Experience including analyzing, research, payments of claims, and

medical terminology.

. Computer skills: MS Word, Excel, and Outlook.

Work Experience

Horizon NJ Health

Quality Management Auditor, Trenton, NJ April 2007 to

Present

. Work to ensure that clinical audits are adhering to protocols of the

state standard, NCQA and URAC regulations, and government regulations.

. Evaluate, monitor, and document study results.

. Prepare year end reports and corrective action plan.

. Exercise good clinical judgment and demonstrate professional conduct

when interacting with Physicians site personnel.

. Monitor physicians' site for Medical record keeping standard and

management of multiple sites per day.

. Assist in complaints/appeals process.

. Support enterprise wide projects by understanding the scope of the

project, assign auditors, ensure timely and accurate project

completion, as well as reporting findings to the appropriate

personnel.

. Perform other related tasks as assigned by management.

. Perform reviews of care providers, sites, facilities, medical records,

and other associated medical-field materials, personnel, and documents

as outlined by the Company either onsite or at remote locations as

designated by the Company. Such reviews includes:

o Care Provider Site Reviews

o Chart Keeping Standards Reviews

o HEDIS Hybrid Chart Abstractions

o Custom QI Reviews

o Care Provider Monitoring Reviews

. Maintain the highest level of professionalism in the communications

and interactions with clients of the Company and staff at sites where

reviews are performed;

. Undergo quality, accuracy, and inter-rater reliability testing and

adhere to Company policies

. Assist with the review and maintenance of policies, procedures, and

training materials which reflect up-to-date NCQA, URAC, and related

regulatory policies

. Adhere to all confidentiality and HIPAA requirements as outlined

within Company's Operating Policies and Procedures in all ways and at

all times.

. Educate providers on all aspects of medical record review criteria

including HEDIS

. Collaborate with providers to improve rates for quality improvement

indicators and standards of care

UMDNJ/RWJMS, Department of Family Medicine, New Brunswick, NJ

Sr. Technical Assistant May 2005 to April

2007

. Collects high quality data via meticulous medical record reviews at

various family practice sites in New Jersey and nearby Pennsylvania.

. Selects and pulls medical records according to protocol.

. Collects data via medical record reviews.

. Assists in data transfer and management, including Teleform scanners.

. Collect and records qualitative data.

. Assists with preparation of study documents and mailings

. Maintains positive relationships with practice site personnel

. Always comfortable working with new billing system to pull extensive

data

. Assist with analysis and data cleaning

. Process report and write extensive field notes

. Randomize client list

Dr Lanez, Private Office, Edison, NJ

Office Manager September 1997-

June 2002

. Performed word-processing, created and maintained spreadsheets, and

prepared PowerPoint presentations.

. Responsible for administrative functions such as filling, data entry,

and visitor relations.

. Performed staff orientation and training, assisted with scheduling.

. Easily established rapport with patients and family members.

. Maintained a professional communication flow with other medical

providers

. Contacted various insurance companies to resolve billing issues and

negotiate claims

. Responsible for logging all discrepancies and correcting non-payment

related discrepancies.

. Conducted in-depth review of bills according with medical diagnosis.

. Follow up with treatment plans as necessary.

. Review Treatment plan documentation.

. Analyze itemized bill and medical records for duplication and

inconsistencies

. Knowledge of ICD9 & CPT CODING.

Medemerg, Piscataway, NJ

Medical Assistant May 1999-

October 1999

. Obtained vital signs and followed up with timely and accurate medical

records-keeping procedures.

. Maintenance of logs and lab notes in computer.

. Perform timely and successful communications of lab results to team

members.

. Interfaced extensively with patients, staff personnel, and physicians.

. Observed and documented changes in patients' conditions and other

matters of concern.

. Completed Clinical form when necessary.

. Ensured the proper use of equipment and medical devices.

Education

Diploma in Practical Nursing from Trinitas School of Nursing, NJ

Licensed Practical Nurse, New York State

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