Customer Service Insurance
Resume:
Thelma V. Henderson
North Charleston, SC 29406
E-mail: **********@*****.***
Summary of Qualifications
Over 10+ years of health administration experience which encompasses Medicare, Medicaid and Commercial Insurance guidelines. Additionally, a vast knowledge of claims, medical billing along with CPT/ICD coding and accounts receivable. Furthermore my outstanding customer service skills have garnered me the opportunity to gain exceptional organizational and time management skills throughout my career. I’m capable of multitasking and communicating effectively with people on various levels. Having proficiency with Microsoft office suite and most office machines along with critical thinking and great analytical skills have afforded me the opportunity to advance in my profession.
Professional Work Experience
Mindlance Temp Agency North Charleston, SC
Utilization Management Technician May2017 – Present
Accurately answers questions regarding plan benefits and utilization management requirements for members and providers.
Makes appropriate inquiries to determine potential coordination of benefits and advises appropriate provider and claims staff.
Incoming/outgoing calls to providers regarding members benefits for various procedures
Facilitates and screens information received via fax/phone from providers to begin the authorization process.
Acts as a resource for questions that providers may have related to the authorization
Supports Utilization management nurses with data entry and other assigned duties.
Molina Healthcare North Charleston, SC
Provider Service Representative (PSR) Mar 2014– Jan 2016
Knowledge of CPT and ICD 9/10 codes was an important element to effectively perform the duties of a provider service representative.
Primarily responsible for claims adjustment and disputes. Initial point of contact for all claim related issues/concerns.
Critical thinking was an important factor because of decisions regarding the outcome based on written response from providers and other outside agencies.
Analytical skills helped to determine the next step in the claims process because we had to identify whether or not the claim was billed with the correct ICD and CPT codes.
Complying with HIPAA guidelines, local, state and federal laws, Medicare regulations and the company’s policy and procedures were mandatory.
Liaison between the provider and the claims and utilization management (UM) departments.
Having input regarding 1st and 2nd level appeals in order to determine if the provider’s claim warrant additional benefits required analytical and critical thinking skills.
Teamwork was very important because many claims required a group effort to ensure that the correct decision was being made, especially, with 2nd level appeal.
Entered provider demographic and contract affiliation information into the health plan to ensure that provider’s credentialing information was loaded properly so that claims can be processed correctly.
Composed correspondence to reflect accurate resolution information in a clear and concise, grammatically correct format.
Maintained a tracking system to follow up on the outcome of claim request reconsideration process.
Served as project leads on specific, complex, multi-dimensional projects assigned by the Director of provider services.
Multitasking was definitely a requirement because we received internal and external calls from various entities in order to resolve provider and claims issue
Having knowledge about the fee schedule was also very important because the CPT code had to align with the component because the payment was based on the conversion factor for that year.
Having knowledge about the precertification system, claims, and configuration was important to effectively performing these duties.
Assisting incoming team members with the necessary tools and material required to perform this job was also a primary responsibility
Excellent customer service skill was a requirement because of the daily interaction with internal and external customers.
Being proficient and having good time management skills was definitely a requirement
Molina Healthcare North Charleston, SC
Provider Information Management (PIM) Dec 2013– Feb 2014
Assisted with the startup of the PIM department at the SC Health plan. Responsible for ensuring that providers were credentialed and uploaded into the QNXT operating system.
Retrieved the necessary documentation needed to begin the credentialing process which included approximately 30 + pages that had to be reviewed.
Ensured that providers submitted the necessary information such as, TIN, facility/location address, license #, affiliates, etc.
Responsible for reaching out to the providers for any missing information in the packet.
To ensure accuracy, our department created a spreadsheet to track incoming/outgoing calls, emails & faxes from internal/external provider representatives so that credentialing process could be more efficient and expeditious.
Information was then forwarded, via fax/mail, to the contracting department to be uploaded in the system.
Filing contracts, answering the phone and interacting with other departments and the contracting team was also an essential part of my job responsibilities.
Odyssey Hospice (Gentiva Company) North Charleston, SC
Site Revenue Coordinator May 2013– Dec 2013
Accurately entered patient/client billing data to reflect the correct rates for various levels of care changes due to the complexity of patients’ condition. Tracking the daily stats for admissions and discharges was constantly monitored for accuracy prior to billing and creating reports.
Coordinates, reviews, and analyzes documentation and data entry supporting Medicare, Medicaid and commercial payer requirements to ensure accurate and timely billing.
Excellent communication skills, strong analytical skill, organized work habits and proven attention to detail is required, along with the ability to work independently and in a team environment
Daily interaction with doctors, hospitals, Medicare, Medicaid and commercial insurance providers, along with patients and caregivers.
Reviewed the verbiage on contracts and letters of agreement to ensure that the fees were aligned with the procedure code prior to obtaining authorizations/billing; in order to eliminate pended claims and denials.
Participating in morning stand up meeting to discuss patient conditions, obtain level of care changes and payer information which is needed to generate various reports.
Obtaining eligibility verification, certification and recertification for Medicaid, Medicare and commercial insurance. Also ensuring that the proper payers have been identified and verified by reviewing the HIQA and secondary payer information if needed.
Generates weekly and monthly accounts receivable reports to ensure accuracy and timely processing of claims billed.
Participates in mandatory weekly A/R review with the Executive Director or Compliance manager to ensure that the weekly/monthly reports are accurate and to determine a resolution for any accounts that’s on bill hold or outstanding.
Processing invoices for room/board and respite service at the end of month and forwarding to the appropriate biller at various nursing facilities.
Also coordinate reviews, analyzes accounts receivable tracking tools and maintain accounts receivable files in order to ensure accurate and timely claim submission to prevent loss revenue.
Assist and responds timely to questions/concerns from the financial service unit to ensure timely filing and collection of receivables. The Executive Director is alerted immediately of seriously overdue accounts.
Alerts the appropriate management team members regarding late or missing documents which are required for billing, so having a positive working relationship with your co-workers is essential.
Sends weekly updates of the unbilled report and Top 10 aging accounts to the VP, Executive Director and Managers of various departments.
Knowledge about CPT and ICD-9 coding is essential to your job performance.
Complying with HIPAA guidelines, local, state and federal laws, Medicare regulations and the company’s policy and procedures are mandatory.
Hill-Rom North Charleston, SC
Documentation Specialist/Customer Payer Service Dept. (CPS) May 2004 – July 2012
To begin the process of placing Hill-Rom’s products, information had to be entered correctly in the JDE accounting system which included the address book, policy structure, and registration, along with supporting documentation.
Knowledge CPT and ICD-9 coding was pertinent to my job performance in order to process claims.
Required knowledge of Medicare, Medicaid and commercial insurance regulations was needed to perform these tasks because specific documentation was required to process claims.
Communicated with doctors, patients, caregivers, facilities and insurance companies on a daily basis to obtain documents needed for billing, i.e., doctor’s order, nursing notes, insurance information, etc., and to resolve grievances and appeals for prior authorization or denied claims.
Communicate with account managers in the field regarding the status of claims and benefits.
Also communicated with the delivery drivers regarding scheduled drop offs to home, hospitals, nursing facilities, etc.
Also spoke with patients, care givers and service technicians regarding delivery, pickup or repair of equipment via phone or by email on a daily basis in order to ensure that the patient’s needs were met.
Duties also include verifying benefits and setting up the account if the referral department was understaffed or if re-verification was needed along w/ assisting team members with their territory.
Training new team members was also part of my duties on this team, which included training them on the proper phone etiquette when talking with facilities, doctor’s office and insurance companies also trained them on how to enter patient’s demographics and other pertinent information associated with billing claims.
Excellent verbal, analytical and customer service skills was also necessary to fulfill my duties.
HIPAA compliant was a requirement for this position, therefore; it was mandatory to take a refresher training course annually.
Attending weekly team meetings was mandatory to discuss process and improvements and issues/concerns regarding our work load.
Hill-Rom North Charleston, SC
Insurance Verification / Long Term Care Division Sept 2002 – Apr 2004
Responsible for all the long term care referrals in this region.
Duties included verifying benefits, registering the patient in the system, setting up the account in IS in order for it to interface with AS400 before forwarding to the insurance team for completion
Knowledge of AS400, FIS and People Soft a must
Communicated with reps, facilities, insurance companies, patients and health care providers via phone or email on a daily basis in order to expedite claim processing
Dial America Marketing Inc. North Charleston, SC
Call Center Shift Manager Oct 1998 - Apr 2001
Responsible for the overall supervision of 10 team leaders and 60 CSR’s on the AM shift
Duties included overseeing the performance of the team leaders which included coaching and developing, delegating specific duties, training of CSR’s on inbound and outbound calls, and assistance with irate callers.
Performance evaluation was done annually to ensure that team leaders were on track. This process allowed both parties to have an open discussion about the skill sets he/she needed to enhance their performance.
Created and developed training material for new groups and also kept materials updated and distributed in a timely manner
Conducted interviews for perspective trainees and team leaders when necessary
Having effective communication and people skills allowed me to motivate my team in a positive manner, which resulted in a unified group of dedicated and highly motivated team leaders.
Maintained service levels for each program
Attended regular conference calls, daily staff meetings and offsite seminars
Bosch Charleston, SC
Quality Inspector/Machine Operator Mar 1985 - Aug 1987
Job consisted of operating the Computer Numeric Calculation (CNC) machinery to produce quality parts for the fuel injectors.
Also responsible for ensuring that the parts were not defective prior to loading and unloading.
Quality inspection of the parts was crucial throughout the production process.
Also responsible for inspecting O-rings under a microscope for the fuel injectors.
Duties included calibration, problem solving techniques and minor repairs.
Also had to maintain a daily log of any down time and problems that occurred during the shift.
Monthly team meeting to ensure that we were meeting our goals.
Education
MUSC/Kay Potter Charleston, SC
Practice Management Coding Curriculum Certificate: Dec 2014
Medical Coding Class
Strayer University Charleston, SC
Master: Health Service Administration (MHSA) Graduated: Dec 2010
College of Charleston Charleston, SC
Major Course of Study: Corporate Communication (BS) Graduated: May 2005
Achievements:
Graduating from Strayer University with a Masters in Health Service Administration while employed full-time was one of my greatest achievements because that took hard work, dedication and perseverance, which are all key components of an exceptional employee.
Reference Provided Upon Request
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