Customer Service Medical
Resume:
Krutha E. Keith
Home: 513-***-****
Cincinnati, OH 45232
Email: *******@***************.***
Customer Service/HealthCare Management
Key Account Management**Direct Network and Partner
Relations** Enhancing Partner and Customer communication
skills**
Profile Steadfast 15 year career reflecting experience in direct
customer service relations and servicing the healthcare industry. Remain on
the cutting edge of technology and healthcare policies through education
and strategic partner relations.
> Expert knowledge in healthcare processes and procedures.
> 15 years of experience in medical terminology including ICD-9 and CPT
coding.
> Success in building and maintaining relationships with customers,
clients, and pharmacy service partners.
> Exceptionally well-organized with a keen eye for details and the
ability to demonstrate self motivation and work independently.
Professional Experience
2000-2008 United Healthcare, Cincinnati, OH.
2006-2008 Grievance and Appeals Coordinator
Responsible for investigating and resolving adverse benefit determinations
within Client timelines. Communicated with all facets of benefit
adjudication departments. Established relationships with physicians,
members, and clients to maximize their knowledge of healthcare policy and
procedures.
Key Achievements:
> Identified and resolved several process improvement strategies.
> Recognized by management for consistently displaying superior
customer service skills.
> Ability to meet or exceed company standards and expectations.
2002-2006 Pre Service Coverage Determination Coordinator
Contributed to company success by handling Care Coordination notification
cases for non-clinical assessment/intervention and providing appropriate
triage. Processed out-of-network requests for consideration of in-network
level of benefits for physician specialty referral for appropriate
products. Processed notification requirements for outpatient procedures,
home health care, DME, transition of care, and network gap issues.
Determined benefit coverage issues based on employer group contracts.
Provided and reviewed documents or triage cases for the Clinical Coverage
Review Dept. Processed Salsa letters and communicated to providers and
members benefit determinations within the DOL time frames.
Key Achievements:
> Generated new relationships and alliances between Partner Relations
and clinical departments.
> Received recognition for providing new processes and procedures that
led to more efficient and documented information.
> Achieved 100% of Appeals quota with 99% accuracy.
> Recognized for applying total quality management skills for clients
and customers.
1998-2000 Pipefitters and MES Local 392 Plumbers, Cincinnati, OH.
Claims Processor and Benefits Representative
Contributed to company success by answering incoming telephone calls,
quoting benefits, processing medical, dental, accident and subrogation
claims. Interfaced directly with hospitals, doctors, attorneys and state
agencies to obtain necessary information to process and approve claims.
Responsible for contacting clinical groups regarding Coordination of
Benefits. Prepared and monitored subrogation agreements, payments and
reimbursements. Communicated with the administrative manager regarding
claim problems and computer system enhancements or problems. Communicated,
monitored and authorized PPO claims through the PPO provider.
Key Achievements:
> Achieved 130% of claims quota within a monthly period.
> Received recognition for providing superior customer service.
Technical Skills
Skilled in Microsoft Office (Excel, Word, and Outlook). Lotus Notes, and
Medical software. Advanced Internet skills. Typing wpm 35-40, Keystrokes
15000, 10 key by touch.
Education and Training
Medical Billing and Coding Cincinnati State Technical College
(present)
Sheppard A.F.B., Wichita Falls, TX
Woodward High School, Cincinnati, OH
Contact this candidate