DEBRA GAWORSKI Bayonne, NJ ● 551-***-**** ● ac0jen@r.postjobfree.com

OVERVIEW

A detail-oriented and analytical with experience in health insurance claims processing and examination. Working knowledge of managed care, healthcare claim reimbursement, and medical billing. Communicates effectively with personnel and clients. Has an understanding of Medical Terminology, Insurance COB’s, Worker’s Comp, CMS, Medicare and Medicaid, ICD9-CM, ICD10, HCPCS and DME coding.

EXPERIENCE

05/2016 to Present Sales Associate 7-11 Inc. Bayonne, NJ

Provide friendly, courteous, and prompt service to customers in a self-service store.

Accurately process payment for purchases while maintaining a clean environment for everyone.

02/2014 to 03/2016 Child Care Provider Self Employed Bayonne, NJ

Cared for a children at home, taught the fundamentals of basic education: shapes, colors, sizes and math.

Helped child learn basic self-care habits such as washing, good eating habits, tidying up and toilet training.

Served as a role model for discipline and good behavior – improving behavior and class participation by 40%.

11/2011 to 11/2012 Claims Analyst/ Claims Auditor Emblem Health New York, NY

Determined Medicare's liability to pay medical claims as the secondary payer through researching data, analyzing and interpreting Medicare’s secondary payer regulations.

Communicated with third parties such as attorneys, employers, or other insurance companies to obtain additional claim information, regarding No Fault, Liability and Workers Comp cases – minimizing delays on claim processing by 50%.

Handled customer and insurance company inquiries timely with professionalism over the phone and email.

Managed confidential health information while working with Government regulated databases, to obtain and update beneficiary information.

Validated other insurance carriers on file to ensure accuracy of information on record as it pertained to member’s eligibility.

Generated Conditional Payment and Demand letters to Third Parties via Word.

10/2003 to 08/2011 Medical Claims Examiner Basil Castrovinci Associates Jersey City, NJ

Greeted, directed and provided information to vendors, customers, job applicants, staff and visitors via phone and in-person.

Resolved complaints from clients, visitors and customers to include, medical coding and billing issues.

Transmitted information or documents to customers using computer, fax machines and mail.

Processed and distributed Fed-Ex and UPS packages, and mail.

Investigated evaluated and settled medical claims, applying technical knowledge and human relations skills to effect fair and prompt disposal of cases and to contribute to a reduced loss ratio of 10%.

Verified and analyzed data used in settling claims to ensure claims were valid and that settlements were made according to company practices and procedures.

Entered claim payments, reserves and new claims on Sys 5 and other in-house systems, inputting concise yet sufficient file documentation to improve accuracy and data efficiency by 50%.

Contacted or interviewed claimants, doctors, medical specialist or employers to get additional information to secure payment.

Reported overpayments, underpayments and other irregularities, saving an average of 1000 dollars a week.

Examined claim forms, and other records to determine insurance coverage.

Reviewed police reports, medical treatment records, medical bills, or physical property damage to determine the extent of liability.

EDUCATION & TRAINING

Medical Coding & Billing, Electronic Health Records Academy of Allied Health Services Newark, NJ

High School Diploma Dickinson High School Jersey City, NJ

Office Automation Certificate School of Business Machines Jersey City, NJ

Microsoft Office Suite Certificate Worldwide Education Services Jersey City, NJ

Word, PowerPoint, Outlook, Excel and Lotus Notes

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