SHARI JOHNSON

**** ********* *****

Houston, Texas 77031

ac5qlt@r.postjobfree.com

713-***-****

OBJECTIVE

Highly motivated and result oriented professional with 10+ years’ experience in Administrative Support and Customer Relations involving but not limited to Medicare and Medicaid analysis of claims, CSP Facets, Diamond platform experience, fee schedules, HCBS products, with excellent written and verbal skills, combined with years of medical terminology with the ability to contribute my acquired skills to the success of any organization and to obtain an entry level training and development position where I can maximize those skills.

SUMMARY OF QUALIFICATIONS

Exceptional interpersonal, communication and public relations skills that allow the development of strong rapport with individuals on all levels. Adept at analyzing and resolving problems and developing and instituting the needed procedures and responses. Consistent high level of performance dealing with people and services requiring strong organizational, time management and negotiating abilities. Results oriented, flexible, creative, service and detail oriented highly motivated to succeed. Energetic and assertive, adept at the coordination and implementation of multi-faceted operational procedures in established operations. A sound professional attitude with pride in personal performance.

CAREER HISTORY

United Healthcare, November 2016 – Current

Senior Claims Appeals Representative

Assisted in streamlining the department focus group which implement key changes

Handle escalated claims, based on experience / knowledge to resolve more complex providers issues.

Research each case file to determine if the provider / representative are authorized to file an appeal or if the complaint is valid, which includes benefits, eligibility, claim payments, deductible limits/ copayments, prescription benefits, eligibility, billing and enrollment inquiries.

Delivers professional communication via telephone/ email to the providers/ members providing them the process of filing an appeal, notifying the provider/member of their appeal status in a timely manner as assigned for each appeal case and obtaining missing or discrepant information.

Partner with other departments (i.e. clinical, claims, billing, etc.) to gather additional information to answer providers questions or to resolve escalated issues. Input and maintain documentation to track and monitor progress of all cases as well as the result to ensure overall compliance; apply key HIPPA guidelines in daily activities.

United Healthcare, March 2014 – November 2016

Provider Service Representative

Answered inbound phone calls from health care providers, physician offices and clinics.

Identify the type of assistance the provider needs regarding benefits, eligibility, claims status /payments and authorizations.

Focus on resolving claims issues and assisting the provider with all questions using the first call resolution process on every call.

Deliver all information and questions in a positive and compassionate manner to facilitate developing a positive relationship with the provider, while providing the best customer service experience.

Ensured the correct documentation is entered to track all provider calls for quality reporting.

Met all required performance goals quarterly in the areas of: Efficiency, Quality, Provider Satisfaction, First Call Resolution and Attendance.

Maintained daily Quality Reporting for the team

Patient Account Services, November 2012 – March 2014

Medical Customer Service Representative (Hospital Accounts)

Work with patients to establish payment plans and arrangements. Answered calls professionally.

Utilized all hospital systems such as McKesson, Epic, Meditech, Centricity, Powerworks, CUBS, Noble Allscripts and LSS. Update patient demographics.

Verify insurance, update patient demographics and monitor the queue to ensure all calls are answered.

Review and interpret patient statements, balances and client contractual terms.

Research insurance and adjustments to ensure proper account resolution.

Review coding to ensure accurate invoice processing. Process and post payments securely and accurately.

ESIS Medbill Impact, February 2012 – October 2012

Provider Relations Insurance Specialist

Responsible for researching, resolving and managing claims projects for Worker Compensation line of

business regarding reimbursement issues, health plan payment methods, benefit coordination and eligibility/enrollments operations also responsible for providing appeal/reconsideration submission info.

Resolved complex provider issues ensuring timely response to escalated provider issues and resolution with root caused mindset.

Ensured the delivery of superior customer services by providing timely and accurate resolution to claims related provider inquiries and complaints regarding claims processing.

Telesure Enrollment Health, March 2011-December 2011

Member Service Representative

Answer incoming calls regarding general billing service related and product questions.

Processed enrollments and applications for new members.

Explain plan’s procedures, protocols, benefits, services and information to members as required. Evaluate member’s needs for medical, dental or life insurance and refer them to the appropriate agent to receive quotes and information.

Set up follow ups and callbacks for members to verify they received all information they request from their agents or to complete application process.

**References and additional information available upon request**

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