Customer Service Medical

**** **** ******, ********, ** *****, 315-***-**** ***********@***.***

Lafarah S.Frazier

Objective

To obtain a position that will utilize my skills and provide

opportunity for professional growth within the Healthcare industry. I

am a Health care professional with 7+ years experience handling all

billing aspects of insurance claims including hospital, physician, and

durable medical equipment in addition to grievance and appeals. I am a

result oriented individual with a solid work ethic and natural

leadership capabilities.

Experience

1/2009-Present Emblemhealth NY, NY

Grievance & Appeals Analyst

*Responds to written and/or verbal grievances, complaints and appeals

submitted by members and providers in accordance with the regulations

by NCQA, CMS, NY State and other entities from all lines of business;

Medicaid, Medicare, Commercial, and Child Health Plus.

* Provide written acknowledgment of all member and provider

correspondence.

*Conduct thorough investigations of all member and provider

correspondence by analyzing all the issues involved and obtaining

responses and information from internal and external entities.

* Interface with HIP's departments, Delegated Entities, Medical

Groups, and Network Physicians to ensure resolution of cases issues.

* Enter all appeals and grievances in the Unit's software tracking

system.

*Ensure appeals and grievances are categorized and processed within

New York State and Federal timeframes.

*Identify potential quality issues and initiate referrals to the

Quality Improvement Department.

* Maintain absolute file integrity with regards to content, location

and confidentiality.

* Manages multiple administrative tasks simultaneously including

filing, scanning, typing and faxing documents.

2/2006-2/2008 Hartford Insurance Syracuse, NY

Subject Matter Expert

*Completed payment or denial of medical invoices from start to finish

for various jurisdictions.

*Performed administrative duties & provided support to team lead.

*Assisted CSR reps with phone duties and other responsibilities

pertaining to customer service department.

*Contacted providers for missing and or incomplete data pertaining to

medical claims.

*Acted as a contact person for claim handlers & insured's.

*Posted payments for penalty & reserves of claims.

*Reimbursed claimants for out of pocket expenses paid.

*Completed request for history transfers & overpayment request.

*Facilitates one on-one-training with newly hired employees.

6/2003-2/2008 Hartford Insurance Syracuse, NY

Medical Bill Processor

*Performed on-line review and investigation of complex medical

invoices to determine reimbursement based on applicable worker's

compensation statues and/or regulations for adjudication purposes.

Types of invoices included hospital, physician, durable medical

equipment and pharmacy.

*Ensured compliance with policy provisions and state/federal

regulations.

*Responsible for verification of accuracy of data submitted

electronically.

9/1999-5/2003 University Libraries-Intra-Library Albany, NY

Loan

Intra-Library Loan Assistant

*Worked collaboratively with the library staff to accurately process

library patron request

*Performed full range of secretarial duties including, but not limited

to: filing, heavy phones, shelf-checks, invoice updating, data entry,

sorting and distributing departmental mail

Education

1999-2003 State University at Albany Albany, NY

BA-Criminal Justice & Political Science

*Distinguished Dean's List Recipient, University at Albany, 1999 &

2002

*Spellman Achievement Award, University at Albany, 1999-2003

References

References are available on request.

Contact this candidate