Customer Service Insurance

MELVA L. ANDERSON

*** *********** ** ****** ****, VA 22546 ? 804-***-**** OR (804)

***-**** ************@*******.***

PROFILE SUMMARY

A highly skilled business professional with exceptional cross-functional

business skills from professional experiences, including role as medical

biller, customer relations representative, collections representative, and

credit analyst. Well qualified to promote into a management and

supervisory role of increased responsibility. Recognized throughout career

for job excellence and instituting best practices in business customer

service delivery. Possess outstanding interpersonal and supervisory skills.

Knowledge of Windows XP, MS Word, MS Excel, MS Outlook, MS Access, Adobe

PDF files, Mainframe, Mysis, Medic, Medisoft and Medical Terminology.

Qualifications & Interests:

( Creating Consensus/Leadership (

Recruiting/Supervising/Training ( Problem

Identification/Resolution

( Establishing Office Infrastructure ( Performance

Improvements ( Banking/Foreign Currency Exchange

( Core General Business Mgmt. ( Strong Success in

Multi-Tasking ( Billing/Collections/HIPPA Adherence

( Organizational Development ( Researching Paper

Trails/Auditing ( Entrepreneurial/Highly Self Directed

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EDUCATION

Virginia Commonwealth University Richmond, Virginia B.S

Business Administration

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PROFESSIONAL EXPERIENCE

Home Care Delivered, Inc. Richmond, Virginia

11/2008 - Present

Insurance Verification Clerk

Communicates with insurance companies to determine appropriate

benefits, required co-pays, documents pre-authorizations, and prorates

bills with management approval, to accurately secure proper reimbursement

from insurance companies and patients. Manage inbound calls on the

Insurance line from patients, clients, physicians, practitioners and

clinics regarding inquires about services provided, financial

responsibility and insurance coverage. Serves as the MIF liaison to the

patient/guarantor, insurance company, and physician office to ensure all

necessary approvals for services rendered and received are documented

appropriately. Enters all necessary pre-authorization documentation into

RMS via the revised schedule information screen to ensure correct transfer

of information for billing, and efficient follow-up with

patients/guarantors and third-party payers. Adheres to departmental

policies, procedures, standards, and protocols to ensure effective

departmental operations and quality patient care. Facilitate prior

authorization with insurance companies for customer receiving same day

shipments. Reviews pre-authorization denial reports provided by the billing

company to ensure accuracy of the pre-authorization process.

World Access Richmond, Virginia 02/2007-

10/2008

International Health Claims Examiner

Provided operational support for activities associated with the

processing and adjudication of claims to include: 1) Data entry of claims

ensuring accurate and timely payment to meet or exceed customer service

level agreements 2) Properly adjudicate claims based on knowledge of

covered benefits, insurance and provider contracts 3) Identify and resolve

issues surrounding pended claims according to established procedures.

Negotiated solutions to adversarial problems in a positive manner. Provided

a high level of customer service while maintaining a continued focus on

quality. Worked with appropriate parties to develop solutions within

authority levels. Followed up and monitored claims error reports as

necessary to ensure appropriate action has been taken. Maintained the

appropriate level of customer service to internal and external customers.

Ensured documentation of issues is current and complete. claims examiner

manages a caseload of insurance claims. Reviewed new claims to assess their

validity, and determined which claims required further investigation.

Providence Service Corp Fredericksburg, VA 09/2005-

02/2007

Accounts Receivables Specialist

Proper recording of all financial transactions, account

reconciliation, preparation of bank deposits,

reconciliation of monthly statements, analyze remittance vouchers, research

outstanding claims, completion of weekly and monthly reports, process

Medicaid and Commercial insurance billing transactions, phone support to

clients regarding billing inquiries, daily reconciliation of cash deposits,

interactions with accounting deposit regarding prompt collection of

returned funds (non-sufficient funds). Reviewed, analyzed and evaluated

accomplishment of various office functions, such as records management and

administrative SOPs. Analyzed existing internal reports to assure

procedures are followed; assisted supervisor in revising mission statements

and the preparation and maintenance of related documentation; maintained

data base of accountable property and operated computer terminal to

input/obtain data from automated systems, requiring the skills of a

qualified typist.

VA Premier Health Plan Richmond, VA 11/2002-

08/2005

Claims Specialist

Identified and investigated possible fraud issues, phone support

to address provider inquiries on medical claims, manually processed

physician and facility medical claims on HCFA 1500 as well as UB 92 using

IDX, researched provider inquiries regarding remits, assisted with the

credentialing of new and existing providers, drafted correspondence to

provides using Microsoft Word, and development and training of staff and

new employees on provider database (DICT 471), billing and collecting on

patient accounts, proper review of claims and filing status, quality

assurance reporting to management, generating and submitting of insurance

claims, audit of coding errors, adjudicate denied and rejected claims,

analyze remittance vouchers. Reviews, analyzes and ensures timely

settlement of mortgage insurance claims covering all financial aspects of

property disposition. Obtained key information and data from attorneys,

providers and patients in order to calculate and determine proper claims

amount.

Identified and reported potential fraudulent occurrences to the

appropriate fraud investigations department. Calculated claim amounts.

Created analysis and made recommendations for claims payment to

management. Assisted in identifying problem areas in processing claims to

allow for more efficient claims flow. Provided support and assistance to

team members as needed. Screened calls and visitors, directed individuals

to appropriate office and responded to inquires on routine policies.

Participated in drafting briefings for the director's presentation.

Reviewed correspondence and prepared replies that did not require

Directors attention, and composed correspondence for director's

signature.

Anthem Richmond, VA 05/1999-

10/2002

Customer Advocate Associate

Received inbound telephone inquiries or paper and electronic

claims from members and providers, resolved issues for members, providers,

group administrators and brokers. Analyzed situations and completed

research to ensure no re-work or follow-up issues were needed. Interpreted

claims to determine primary of secondary liability and recognize when

additional information was needed. Interacted with system to ensure claims

are paid or denied based on terms of contract, Initiated interaction with

other area to ensure claims are handled properly and thoroughly.

Demonstrated ability to listen effectively, and used probing skills to

obtain relevant information and establish rapport quickly with customers

and co-workers. Entered, manipulated, and/or retrieved information,

completed request forms, handled complaints, provided policies, procedures,

and locations information. Maintained patients' records and researched

files, ensured the patient completed forms, verified and assured the record

of the patient treatment was administratively complete, performed Quality

Assurance monitoring. Also was responsible for the clerical duties when

receptionist back-up was needed, typed progress reports, medical

statements, memorandums, and statistical reports

Certifications/Training/Awards: CPR Certified, C.N.A Certified, Med Tech

Certified

Leadership Skills for Non Supervisors, 16 hours, The

Graduate School, USDA, January 2006

Building Great Web Pages, Hands on Training, 16

hours, Learning Tree International (2001)

Financial Management 3 Credit Hours, August 2008 Walden

University

Received several outstanding work performance awards.

References: Available upon request.

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