Customer Service Insurance

Michelle Hayward

** ******* ***., #*

Boston, MA 02125

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

857-***-****

OBJECTIVE:

To obtain a secure position in which both personal and professional growth

can occur.

SKILLS SUMMARY:

Customer Service/Call Center

Medical/Dental Terminology

Life, Universal, Variable Insurance

MS Word, Excel, PowerPoint, & Windows Mainframe

Apps

MCO, HMO, PPO, POS & Dental -ALL Insurance plans

Annuities & all Related Retirement Plans

Crystal Reports

AS400

MEDITECH

FISS

MMIS

PROFESSIONAL EXPERIENCE:

New England Baptist Hospital

Patient Account Representative

2/2010-present

. Prepares and submits clean claims to various insurance companies

either electronically or by paper

. Claims follow-up, working on aging reports, answering billing

questions, handling claims, monitoring payment/denial activity,

ensuring adjustments are processed accurately,

. Completes billing on assigned carrier accounts.

. Resolves coding and charge errors with hospital departments.

. Prepares a weekly billing report of all accounts billed and

unbilled

. Responds to third party inquiries regarding billing errors, coding

and medical documentation.

. Pursues assigned billed accounts with third party payers

. Conducts audits of account folders and corrects the errors

. Posts payments that are received to proper patient account folders.

. Prepares refunds as needed

. Evaluates patient's financial status and establishes budget payment

plans. Follows and reports status of delinquent accounts.

. Acute hospital billing. Inpatient & Outpatient.

New England Hematology/Oncology

Billing Coordinator/Third Party Biller 6/2009-1/2010

. Sort and mail all bills (HCFA 1500) attaching any required

documentation needed to receive payment (i.e. EOB for other secondary

insurance, cost invoice, operative notes, etc.)

. Review rejection/denials from insurance carriers to determine what

actions have been taken

. Account resolution may require calling insurance carriers, patients,

lawyers, physician offices, medical records and other third parties

. Work claim edits to fix claims that are not accepted by the payers

electronically

. Review aged trial balance and research outstanding patient accounts

. Handle all additional follow-up required to get a claim processed and

paid

. Responsible for daily review and processing of insurance claims,

verifying accuracy of encounters, entering charges, posting insurance

and patient payments, maintaining assigned AR, and follow up on self

pay statements/budget plans

. Payors include: Medicare/Medicaid, BCBS, HPHP, Tufts & all commercial

plans.

Multiplan

Billing Issue Resolution Specialist 4/2008-6/2009

. Independently reviews and resolve practitioner and facility

claims/complaints and client explanation of benefits to determine

whether the allowed payment was appropriate

. Review provider history and/or claims information

. Complete practitioner and hospital claim resolution within department

guidelines

. Communicate consistently and accurately with practitioners and

hospitals until inquiry/case is resolved including conference calls

when necessary

. Respond to client questions regarding appropriate interpretation and

reimbursement of contracts

. Where necessary contact clients clearly and effectively to request

adjusted claim payments

. Act as a liaison for append clients and internal claims staff by

responding to questions regarding interpretation and reimbursement of

practitioner claims

. Verify practitioner and hospital status, rates and claim information

provided

. Identify trends, assist in training and work with department

management to improve workflows and procedures

. Reprocess claims per contract on file for facility or hospital

. Reviews claim information and accurately enter HCFA/CMS and UB data

from the claim form into the computer system by following specific

guidelines and procedures

. Work closely with internal staff to identify root cause issues and own

resolution

. Provide thorough and appropriate responses, initiate, coordinate and

resolve issues to meet the goals of the department

Boston Medical Center Healthnet Plan

Senior Claims Resolution Unit Analyst 7/2006-3/2008

. Respond to all provider phone calls and correspondence including

claims adjustment requests, appeals, corrected claims, timely filings

and claims projects

. Resolve complex issues as referred by CRU Analysts

. Assist with the development of orientation and on-going training

programs for CRU stafF

. Maintain current knowledge of BMCHP benefits, provider network

development and contract issues, Massachusetts Medicaid regulations,

as well as industry standards for claims adjudication and other party

liability issues

. Adhere to HIPAA guidelines

. Analyze reports to identify trends, routine errors, or other issues

with provider contracts, system configuration or state regulations

. Report problems and trends to the Manager of CRU along with

recommendations for process improvement

. Maintain department production and quality requirements

. Utilize all resources possible to obtain updated information, payor

websites and NEHEN to verify eligibility and claim status whenever

possible

. Coordinate special projects as assigned

Claims Resolution Unit Analyst

. Respond to provider phone calls and correspondence including but not

limited to' claim adjustment requests' appeals' corrected claims'

timely filings' and claims projects

. Maintain current knowledge of BMCHP benefits' provider network

development and contract issues' HIPAA regulations' Massachusetts

Medicaid regulations' as well as industry standards for claims

adjudication and other party liability issues

. Adhere to HIPAA guidelines

. Report problems and trends to Manager of Claims along with

recommendations for process improvement

Network Health

Provider Service

Representative 10/2004-

6/2006

. Serve as the primary contact for providers and members with questions

related to claims, benefits, member eligibility, timely filing,

appeals and other topics related to Network Health

. Interface with claims, enrollment, IS, network management, pharmacy,

behavioral health, and other internal teams to provide service

excellence to our customers

. Assign primary care provides to members as necessary

. Meet all department standards regarding call center-related activity

. Maintain confidentiality of information at all times

. Consistently support Network Health's approach to service excellence

by adhering to established department and company standards for all

work- related functions

. Perform other duties as assigned by the director of customer service

. Assist marketing department with pilot program by making outbound

calls to prospective members & educating new members about their

health insurance benefits

John Hancock Signature Services

Business Analyst/Field Service

Representative 11/2001 to

4/2004

. Provide quality customer service by responding to incoming

agent/broker via telephone and transaction processing

. Review and process pre/post issue transactions resulting from written

requests including policy changes and monetary transactions. And

explain underwriting procedures

. Research and resolve complex inquiries

. Review and monitor pending requirements for pre/post issue processing

and maintain open communication with agents/brokers to obtain final

requirements

. Carry out administrative service associated w/processing functions

including financial/non-financial transactions

Disability Claims

Representative

. Process premium payments for disability policies

. Process waiver for claims if insured disabled

. Send out regular & irregular billing notices

. Calculate premium payments based on age & work status

. Interact w/UnumProvident and third party vendors for claims

information on client

. Make adjustments and reprocess claims. Cancels policies, issue return

of premiums to client

. Receive inbound & outbound calls from insured/agent.

. Created new policies if changes are made to existing policy

Customer Service Representative

. Help existing life insurance customers & service agents with their

policies

. Process loan, surrender and dividend request

. Verify premium payments & process premium

. Check on status on claim and interactive operation area

. Update database with correct address and customer information

. Verify benefits & assist w/processing death claim

. Crossed train on Annuities, 401K, TSA's,403B & Retirement

Plans

EDUCATION:

Bunker Hill Community College Charlestown, MA

Major: Criminal Justice 9/94-9/95

Dorchester City Roots Boston, MA

Graduation 1994

References Available Upon Request

Contact this candidate