Customer Service Quality Assurance

Brenda G. Taylor

**** ******** **** ********* *** ? Mayfield Heights, Ohio 44124 ? (817) 909-

**** (cell) abnawc@r.postjobfree.com

PROFESSIONAL OBJECTIVE____________________________________________________

Customer Satisfaction... Claims Examiner... Account Representative...

Benefits Analyst... Client Service Representative... Customer Service

Representative... Healthcare/Insurance Industry

SUMMARY OF QUALIFICATIONS_______________________________________________

Medical insurance professional with more than 14 years of extensive medical

claims adjudication and customer service experience. Effective oral and

written communication skills. Comfortable in deadline-driven environments.

Maintained established productivity, schedule adherence, and quality

standards. Excellent team-building and staff development skills

SKILLS & KNOWLEDGE SUMMARY____________________________________________

Medical Procedure Terminology, Working Knowledge of Legal Concepts

Anatomy and Workers' Compensation Law

and Surgical Terms

ICD-9, CPT, HCPC, Coding OSHA Regulations

Familiar with HCFA and UB Forms Computerized Claims Paying Systems

Medicare Policy and Pricing Microsoft Word and Excel

Guidelines

HMO, PPO, POS, Policy Interpretation Coordination of Benefits

Fee Schedules, U&C Rates Subrogation Investigations

HIPPA Guidelines Claims Processing Training and

Auditing

TPA, Insurance Company, Managed Care, Claims Research and Problem

Insurance Call Center, Experience Resolution

COBRA

PROFESSIONAL EXPERIENCE__________________________________________________

Council For Economic Opportunities In Greater Cleveland, Cleveland, Ohio

March 2004 - September 2008

Risk Management and Safety Program Assistant

Compiled efficient maintenance records system for Workers' Compensation

claims and related information data and activities. Composed various legal

documents, including settlement negotiations. Developed new

accident/incident reporting forms. Identified potential health and safety

hazards. Prepared statistical data to evaluate loss control strategies.

Worked under supervision of Risk Manager & Safety Attorney.

Family & Community Partnership Monitor

Monitored performance standards at child daycare centers. Created and

implemented organizational format to capture relevant data related to

local, state and federal regulations, standards and licensing requirements.

Provided technical and training assistance to daycare staff as part of the

monitoring process.

MHN/Healthnet, Irving, Texas

January 2003 - December 2003

Customer Service Representative

Provided claims resolution services in call center environment to members

and providers regarding billing and payment issues. Verified eligibility

and benefit information, processed adjustments, provided stop

payments/reissues for checks. Communicated with intake specialists and

utilization managers regarding authorizations for treatment. Resubmitted

claims for TPA accounts.

.

Brenda G. Taylor

Resume... Page 2

National Insurance Health Company, Grand Prairie, Texas

August 2001 - September 2002

Claims Examiner

Processed individual and small employers' health insurance claims,

according to terms of policies, riders, and state mandates.

GE Group Administrators, Arlington, Texas

January 2001 - July 2001

Benefits Analyst

Processed TPA claims for multiple employer groups. Provided customer

service to providers, employers and members.

PacifiCare (Formerly Harris Methodist Health Plan), Arlington, Texas

January 1995 - January 2001

Claims Processor III

Processed group medical claims according to TPA, HMO, PPO, POS and Medicare

policies and procedures. Provided oral and written communication to

providers and members. Processed claims adjustments and refunds. Mentored

new staff members.

North Texas Healthcare Network, Irving, Texas

October 1990 - January 1995

Team Leader, PPO Department

Supervised claims examiners, customer service representatives, and clerical

workers. Maintained daily production quotas and turnaround times. Trained

all new employees in all phases of PPO guidelines. Audited claims for

quality assurance. Implemented new department guidelines to achieve

organization and efficiency.

Claims Examiner

Re-priced claims PPO claims. Processed group dental, TPA and PPO claims.

Provided customer service and handled correspondence. Coordinated

inquiries among departments to create continuity and seamless quality

service.

EDUCATION

Florida A&M University, Tallahassee, Florida

Bachelor of Science Degree in Animal Science

Texas Women's University, Dallas, Texas

Graduate Studies in Healthcare Administration

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