Customer Service Representative

Gretchen W. Barton

**** *****

Highway ***

Guin, AL 35563

Cell Phone: 251-***-****

PROFESSIONAL ORGANIZATIONS

Certified Fraud Examiners: Associate Member 1991 - 1997

Appointed to the Governor's Task Force on Health Care Fraud: Member 1995 -

1997

EDUCATION

1969 - 1972 Somerville High School, Somerville, MA

BLUE CROSS BLUE SHIELD CONTINUING EDUCATION

Phone Skills

Supervisor Training

Stress Management

Creative Writing

QMF for End Users

Interrogation Skills Training

Level II Training for Health Care Fraud Investigators

Managed Care and Its Implications for Anti-Fraud Specialists

HEALTH INSURANCE RELATED WORK EXPERIENCE

3/04 - 9/10 FAIRHOPE PHYSICAL THERAPY SERVICES, INC.

Office Manager

Duties: Responsible for all insurance and patient billings,

verifying insurance benefits, filing corrected claims

with supporting documentation to facilitate their prompt

adjudication, posting all insurance and patient payments, collections

issues, dealing and negotiating with attorneys and

third party insurance regarding accident related

treatment, assist patients with billing issues, monthly and annual

reports, supervise office assistant, interview, hire and train new office

personnel

for this and sister offices.

5/03 - 03/04 ALABAMA ORTHOPAEDIC CLINIC

Blue Cross Blue Shield/Medicare Insurance Collector

Duties: Assist patients with billing issues, update

insurance information in patients' files, work balance

aging list by contacting insurance companies and Medicare,

filing corrected claims, and providing supporting

documentation to facilitate the insurance companies in

claim adjudication, contact patients regarding past due

balances, collection of NSF checks, fill in when needed at

the front desk by assisting patients in updating insurance

information, accepting copays and maintaining the patients

file and assist in training new employees.

7/01 - 3/03 UNITEDHEALTHCARE

7/01 - 1/02 Customer Service Representative

Duties: Assist members, providers and employers with

benefits, eligibility, membership and premium issues,

update membership files, change primary care physicians and add

and terminate employees on group accounts. Assist in on the job training

of new employees and mentoring employees who need

additional assistance to maintain corporate quality

standards.

02/02 - 03/03 Appeals Coordinator

Duties: Respond to written inquiries received from members,

providers, agents and employers regarding claims, benefits and

eligibility issues. Research and reply to Executive Level

Complaints and Department of Insurance Complaints. This requires

extensive knowledge of claims adjudication and corporate

reimbursement

methodology. Instruct the Claims Department on how to

reprocess claims involved in these issues.

10/00 - 5/01 TELE - DATA

Customer Service Representative

Duties: Assist members and providers with claims and

eligibility problems. Maintain standards of excellence.

9/98 - 7/99 BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA

Customer Service Representative

Duties: Assist subscribers and providers with claims and

membership problems, adjust claims, update membership and other

carrier liability information, assist in the

training of new employees, assist management with reports and identify any

system problems and report them to the appropriate

departments.

8/83 - 5/97 BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA

83 - 85 Customer Service Representative

Duties: Assist subscribers with claims and billing problems.

85 Dedicated Claims Processor

Duties: Coding claims using ICD and CPT codes, claims

processing, customer service related responsibilities and

membership service responsibilities to dedicated groups.

86 Work Leader

Duties: In addition to the above listed duties I did Quality

Assurance for the other claims processors, assisted with problem

claims and was responsible for all special projects.

87 - 90 Investigative Assistant

Duties: Assist the investigators in research and development

of fraud and abuse cases.

90 - 97 Investigator

Duties: Identify fraudulent activity by means of research

for cost containment, conduct investigations, perform

undercover assignments, conduct interviews necessary to the

development of the case, present cases to and assist law enforcement in

development of fraud and abuse cases for prosecution, testify

at court proceedings, train and assist investigative assistants

in investigative techniques, draft written reports on completion of

each investigation and report investigative findings and make

recommendations for the correction of unsatisfactory

practices. Developed extrapolation method for restitution.

References Available Upon Request

Contact this candidate