Customer Service Medical

Frank Simmons

**** ***** ** ******** ******* ~ Kennesaw, GA 30152

Cell: 678-***-**** ~ ac22uy@r.postjobfree.com

SUMMARY OF QUALIFICATIONS

A Healthcare Claims Processing Professional with over 19 years of leadership, training coupled with increasing diverse experience in the healthcare insurance industry. Demonstrated extensive knowledge of Indemnity, PPO, HMO, POS, and Georgia State Medicare and Medicaid plans. Able to utilize excellent communication skills when training staff on industry policies, practices, managed care guidelines, and reimbursement methodologies. Regularly exceeds quality customer relations and volume productivity, auditing and discrepancy resolutions.

Recent Performance Review Key Words:

Initiative Detail Oriented Follow-up Critical Thinking Results Driven Exceed Goals

Motivated Productivity

Leadership Problem Solving Team Player Communication

Technical Skills:

2010 Microsoft Suite, Document Direct, Document Analyzer,

Centricity, Gateway, Track EDI, Verinet, NASCO, QCARE, Amisys

Professional Experience:

Payment MD ~ Atlanta, GA 03/09 – 09/17

Accounts Receivable Specialist

•Processed high-dollar DRG per diem claims and directly interfaced with hospital staff in the resolution of stop-loss and other payment discrepancies.

•Resolved unpaid medical, auto, and worker’s compensation commercial emergency room claims.

•Self-audit of E/M coding per CMS guidelines; Billed HCFA claim forms via Centricity system.

•Used extensive knowledge of Indemnity, PPO/POS/HMO/Medicare and Medicaid plans to process claims.

•Trained new and existing staff on various claim applications, Explanations of Benefits documents and self-audit techniques.

•Regularly volunteered to help customer service team take inbound call on high volume days.

•Created detailed reports, correspondence to providers, hospitals and healthcare industry plan administrators.

Frank Simmons Cont’d

Blue Cross Blue Shield of Georgia ~ Atlanta, GA 01/91 - 06/07 Senior Claims Associate / Claims Examiner

Trainer of new and existing employees on company claim applications, policy and guidelines.

Processed complex medical claims as well as served as a liaison between Blue Cross Shield (BCBS), hospitals, and medical providers

•High volume healthcare claims facilitator, demonstrating a strong knowledge of medical terminology, coordination of benefits, third party claims healthcare procedures insurance regulations, company guidelines and reimbursement methodologies.

•Utilized leadership decision making, human resources, and conflict resolutions skills in the role of supervisor in lieu of the manager.

•Processed high dollar DRG per diem claims as liaison directly interfacing with hospital staff resolving stop-loss and other payment discrepancy issues on regular basis.

•Evaluated and processed claims via NASCO and QCARE claim application systems.

•Identified system-wide coding errors; teamed with IT department to resolve and eliminate payment discrepancies within the systems.

•Exceeded customer relations expectations; consistently had high volume productivity rate exceeding department set goals by 65%.

•Routinely played role of team auditor preventing over payments and under charges that resulted in an 85% annual savings in excess $100k+ dollars.

Assurant Solutions ~ Atlanta, GA 04/08 - 12/08 Insurance Specialist I

•Utilized communication skills handling inbound customer inquiries in a high volume call center environment.

•Corresponded and follow-up with external clients as well as internal departments.

•Identifying, analyzing, and resolving customer and client processing problems.

•Processing and supporting daily office functions.

Peachstate Health Plan ~ Smyrna, GA 12/08 – 12/07 Consultant

•Developed Excel spreadsheets from existing data; Identified and analyzed insurance data to recoup over and under payments.

•Devised and presented new system payment processes for future income revenue to leadership team.

•Researched, located and contracted medical providers discussing acquiring new patient availability status.

•Analyzed research customer inquiries/grievances data and provided action plans recommendation.

•Preformed audit of client systems to ensure enrollment database accuracy. Reviewed with leadership team.

•As part of consultation, provided spreadsheet calculation reports, logs of overpayments, recoupments and other miscellaneous reports where future revenues maybe overlooked.

•Built a spreadsheet of eligibility and status on Medicaid clients with built-in coding and formulas to extract quick run reports for self-auditing.

Education: High School GED

Professional and Personal References Upon Request

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