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Customer Service Medical

Location:
Marietta, Georgia, 30067, United States
Posted:
May 25, 2010

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Karnese T. Thornton Summary Qualification

**** ****** ***** **** **** 8 years experience as a Claims Analyst.

Road Extremely

Apartment D knowledgeable with regards to medical coding

Marietta, Georgia guidelines and coding

30067 techniques (ICD-9, CPT-4, HCPCS, and DRGs),

Cell: 706-***-**** proficient in physician

karnese.thornton@gmai coding, inpatient hospital coding, outpatient coding,

l.com and facility

Career Highlights coding. Strong knowledge of Anatomy and Physiology,

Eight years of Medical

quality performance Terminology, Psychology, and Pharmacology. Very

in claims, health proficient in using MS

plans Office Software, including MS WORD, EXCEL, POWER

processing/adjudicati POINT, ACCESS and

on and analysis OUTLOOK. Able to type 45-50 wpm and 350+dpm. Possess

leading to claim excellent

validation and interpersonal, organizational and time management

benefits assignments. skills, problem solving, analytical and communication

capabilities. Ability to work in a production

Achieved maximum environment and be goal oriented. Success in

results consistently developing effective relationships with multiple

every month: 100-110% individuals, and demonstrated multi-task

claim processing capabilities, including organizing, prioritizing,

rate; 98-100% working effectively under pressure, and operating

accuracy rate of autonomously with minimal to no supervision and

manual claims forms: direction.

HCFA 1500, CMS 1500,

UB-04, ADA-94,

Dental, EHER, Super Key Accomplishments

Bills, Vision,

Hearing,

Prescriptions and

DME/Home health.

Extensive knowledge

on health care

coverage plans and

products: HMO, POS,

PPO, Indemnity,

Federal, Medicare,

Medicaid, SCHIP,

TRICARE, VHA, FSA,

HRA, HSA, HDHP, CDHC,

third party payer

Awards

"Top Performance"

Award, 2002-2009

Impact Award, "No

Processing Errors"

for the year, 2005

"Service Excellence"

Awards, 2003-2009

Documented experience in Proficient in HIPAA

billing/ medical insurance Laws and Regulations

coding Knowledgeable in

Troubleshooting/ Problem Medicare/Medicaid

Solving Reimbursement

Technical/User Support Clinical Data Analysis

Assist in the development, and Extraction Expert

installation, monitoring and Knowledge of various

evaluation of claim systems health licensing,

and operations reimbursement and

Maintained databases of accreditation standards

medical providers and various

health networks

Professional Experience

August 2001-August 2009 Blue Cross Blue Shield GA,

Columbus, Georgia 31904

Business Analyst I (June 2009-August 2009)

Define, plan, coordinate and obtain information

requirements to support and launch new products and

software releases to maximize claims

auto-adjudication

Perform analysis for business applications,

researched and tested document issues

Responsible for loading and testing fee schedules,

including fee schedules from external sources

Responsible for claims payment edits and worked with

the claims staff to ensure accurate and timely claims

processing and adjudication (EDI: ASC X12 835 and

837)

Partner with the business and IT groups to find

solutions for project and operational issues

Translated business requirements to claim processing

staff to ensure that requirements were incorporated

into system design

August 2001-August 2009 Blue Cross Blue Shield GA,

Columbus, Georgia 31904

Senior Claims Analyst (August 2001-June 2009)

Understanding of health insurance applications,

benefit contracts, pricing (accounts payable) and

medical processing policies, procedures and medical

billing/coding (accounts receivable)

Adjudicated claims for assigned products; proof of

all claim submissions for required reviews from

various commercial insurance carriers including

Medicare and Medicaid, medical necessity, coverage

benefits, and cost containment to ensure appropriate

adjudication

Meet individual quality and productivity standards

for assigned claim adjudication function

Responsible for handling complex claim research

scenarios and serving as a technical resource to

colleagues on claim resolution of claim

pre-authorization and pre-certification issues and

similar situations requiring senior level expertise

Perform medical claim adjustments

Process claims in a timely manner

Outstanding customer service skills

Excellent knowledge and understanding of HIPAA laws

and guidelines

October 2000-August 2001 Total Systems, Columbus,

Georgia 31906

Customer Service Representative (October 2000-August

2001)

Develop and maintain knowledge to effectively

research and resolve "Customer Care Basics". The top

calls across several areas/calling queues

Complete/Conduct daily workload activities while

meeting and/or exceeding defined expectations of:

o Inbound call volume handling

o Quality of customer interactions

o Accuracy and Timeliness of Transaction Processing

Process requests and transactions in accordance with

bank policies and procedures of the Contact Center

Effectively utilize process and procedure manual,

bank sponsored trainings and software applications to

answer incoming customer inquiries

Education

Troy University, Fort Benning, Georgia (Major:

Business Administration, Minor: Computer Science)

2006-present

Chattahoochee Valley Community College, Phenix City,

Alabama (Major: Business) 2000-2001

Carver High School, Columbus, Georgia (Diploma:

College Preparatory Plus) 2000



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