Customer Service Quality Assurance
Resume:
MAXINE ELLIOTT
HIXSON TN. *****
JOB OBJECTIVE
A POSITION WITH NEW CHALLENGES AND ADVANCEMENT
OPPORTUNITY USING THE SKILLS AND KNOWLEDGE OBTAINED FROM PREVIOUS
WORK EXPERIENCE.
EXPERIENCE
CARITEN HEALTHCARE/ HUMANA: CHATTANOOGA TN.
BENEFIT ANALYST III /SENIOR PROCESSOR 1996- 4-30-2010
PROCESSED MEDICAL CLAIMS FOR MULTIPLE ASSIGNED GROUPS. ANALYZES EACH
CLAIM BY IDENTIFYING MEDICAL DIAGNOSIS AND RESPECTIVE TREATMENT IN ORDER TO
DETERMINE WHETHER TO PAY OR DENY OR PEND IN ACCORDANCE WITH THE GROUP'S
PLAN DOCUMENT AND NETWORK PROVIDERS CONTRACTS. DISCERNS NECESSITY FOR
MANUAL PROCESSING AS DETERMINE BY ESTABLISHED POLICES AND PROCEDURES.
MAINTAINS ACCURATE MEMBER-SUBSCRIBERS ACCUMULATORS. INVESTIGATES AND
RESPONDS TO CUSTOMER SERVICE FORMS. ORGANIZES AND PRIORITIZES NEWLY
RECEIVED AND PENDED CLAIMS TO ENSURED TIMELY PROCESSING. GENERATING SYSTEM
LETTERS TO MEMBERS AND PROVIDERS REQUESTING ADDITIONAL INFORMATION FOR
COMPLETION OF CLAIMS. REVERSE AND ADJUSTS CLAIMS THAT HAVE PREVIOUSLY BEEN
PAID. MAINTAIN MAJOR JOB OBJECTIVES STANDARDS. STRONG KNOWLEDGE OF THE
AMISYS, CSC, I MAX AND NOVELL SOFTWARE. STRONG KNOWLEDGE OF PPO, HMO, POS,
SELFUNDED, MEDICARE AND TENNCARE PRODUCTS AND THE EDITING SYSTEM OF ICES.
STATE FARM INSURANCE CHATTANOOGA TN.
CUSTOMER SERVICE REPRESENTATIVE 1995-1996
QUALIFIED IN TELEMARKING RESEARCH, CANVASSING FOR NEW
BUSINESS DEVELOPMENT RESPONSIBLE FOR WALK-IN CUSTOMER WITH MAJOR FOCUS ON
CUSTOMER SERVICE AND SALES INCLUDING IN-DEPT SALES PRESENTATION COVERING
PRODUCTS AND SERVICES FOR THE MARKETING OF AUTOMOBILE LIFE, FIRE AND HEALTH
INSURANCE. STRONG KNOWLEDGE OF THE ECHO SOFTWARE SYSTEM. PROFICIENT WITH
DATA SEARCH, RATE QUOTES CLIENT BACKGROUND INVESTIGATIONS INCLUDING
PRELIMINARY UNDERWRITING CLIENT LIAISON AND CLAIMS FILING PROCEDURES.
MAINTAINED A 90% CLOSING RATE ON ALL QUALIFIED PRESENTATIONS. AVERAGED
OVER 75% IN RELATED SALES OF ADDITIONAL INSURANCE COVERAGE FOR OTHER
LIABILITIES.
HEALTHSOURCE/PROVIDENT: CHATTANOOGA TN .1986-1995
MEDICAL CLAIMS ADJUSTER III
PROCESSED CLAIMS FOR BASIC AND MAJOR MEDICAL PLANS IN THE
DETERMINATION OF BENEFITS. INCLUDING INVESTIGATION AND INTERPRETATION OF
POLICY AND PROVISIONS OF STATE AND FEDERAL LAWS. MAINTAINED INFORMATION ON
ALL PROCEDURES AND ENHANCEMENTS OF SYSTEMS AND NETWORK BASED ON MANAGED
CARE PROVISION. KNOWLEDGEABLE OF CLAIMS ADMINISTRATIONS AND SYSTEMS
ADJUDICATION. QUALITY ASSURANCE CROSS TRAINING, CUSTOMER SERVICES, ERICA
APPEALS. FLAGGED PROVIDERS AND PRE-EXISTING INVESTIGATIONS. HEADED VARIOUS
RESEARCH PROJECTS. PROGRAMS USED INCLUDED IMS AND PROCLAIM.
ELIGIBILITY
CLERK:
ENTERED POLICY HOLDER INFORMATION TO SIMPLIFY THE TRANSLATION OF
CLAIMS AS THEY ARE PRESENT FOR PAYMENT. EXCELLENT KNOWLEDGE OF MEDICAL
TERMINOLOGY. PROFICIENT IN OPERATION OF ICD9 AND CPT4 CODES. EXTENSIVE
BACKGROUND IN MANAGED CARE PPO NETWORKS AND HMO NETWORKS.
EDUCATION:
NORTH PLATTE SENIOR HIGH SCHOOL NORTH PLATTE NE.
MID-PLAINS VOCATIONAL SCHOOL NORTH PLATTE NE
CAREER
EDUCATION:
PHOENIX CERTIFICATION COURSES:
LIFE UNDERWRITING
LETTERS AND MEMOS
EFFECTIVE ENGLISH
DEAN VAGUE MEDICAL TERMINOLOGY
INSURANCE AS A CONTRACT
PERSONAL LINES INSURANCE
SELF-ESTEEM SEMINARS
REFERENCE:
PASTOR RODGER REDMAN- NO.RED BANK BAPTIST CHURCH 488-7700
ESTHER BUCHANAN- SUPERVISOR CLAIMS WORK 1-865-***-****
KAREN FENSTEMAKER-SENIOR LEAD 718-3790
JUNNITA STONE- SENIOR PROVIDER RELATIONS REP 821-8080
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