Medical Customer Service
Resume:
Cheryl A. Davis
Skills & Experience:
- Customer Service skills, assist clients with explanation of benefits and payment issues.
- Analyzed and discussed complex claims issues with Coordinator of Benefits and Third Party Carries.
Supervisory & Leadership Skills
- Team Leader of Claims Department
- Supervised the Billing and Coding Departments
- Required SF86 Clearance Public Trust
Education: Institute of Computer Science: Philadelphia, PA. (Certificate of Completion)
Overbrook High School: Philadelphia, PA (Academic Graduate)
EMPLOYMENT EXPERIENCE:
Harris Corporation-Clinical Data Abstractor 01/2013 to Present
Abstract and enter data accurately and on time, in accordance with data abstraction business rules and SOPs.
Conduct data abstraction at accuracy rate of 98% or higher.
Perform self-audits and peer-reviews to ensure meeting the quality requirements.
Assist supervisors and program management in coordinating and producing reports for special projects.
Ensure consistency, accuracy and adherence to federal regulations, Good Clinical Practice, Good Clinical Data Abstraction Practices, as well as SOPs and Working Instructions.
Manage patient information according to privacy and security regulations including but not limited to HIPAA and The HITECH ACT and according to project specific- privacy and security policies and procedures.
Develop and maintain good communications and working relationships within project staff and management team.
Communicate project status and key project issues to management.
Perform other duties and tasks as directed by Clinical Staff or Project management.
Clearance Received by OPM.
TheraCom Pharmaceutical LLC- Reimbursement Case Advocate 11/2011 to 11/2012
Case Manage Patient Treatment therapies for the medication Gilenya for patient with MS.
Arrange Patient Care Services for patients by scheduling appointments for pre-screenings requirements.
Schedule patients for First Dose Observation to ensure that the therapy is suitable.
Refer patients to Specialty Pharmacies for medication management.
Provide financial assistance for patients that are uninsured and underinsured.
Verify eligibility for commercial, Medicare and Medicaid insurance companies to obtain benefit coverage.
Follow up for prior authorizations and appeals.
DC Chartered Health Plan- Care Coordinator Specialist 7/2008 to 9/2011
Duties and responsibilities are to use a multi-disciplinary approach to engage the member, member's family, PCP and specialist to participate in plan medical and behavioral health services.
Consults with the Chartered case managers assigned to manage the member with specific disease and conditions to determine service levels and assist in coordination as needed.
Assisting members to gain access to and/or schedule medical, social, educational and other services, both within and outside of Chartered network working with the Children with Special Needs.
Help Case Managers to assist member with arranging for Medically Necessary IDEA services.
Assist in working with inpatient nurse reviewers to plan and arrange for services for members indicated in the hospital discharge plan.
Phone verifications for Authorizations and Referral request for patients and physicians.
Chartered Family Health Center- Medical Billing/Patient Account Coordinator 2/2002 to 7/2008
Verify Medicaid and Commercial claims submitted for billing process and payment posting to insurance carriers. Process various types of reports and calculate posting data.
Knowledge of CPT and ICD-9 codes maintain timely processing for all claims according to the Medicare guidelines.
Prepare claims for Electronic Date Transition, audit all encounters for errors and make corrections as needed.
Review denials to determine what type of follow-up is needed to resubmit the claims for reimbursement.
Contact and advise the insurance carriers of claim status for payment. Provide training to providers as needed to ensure encounter accuracies.
Children's National Medical Center- Patient Account Representative 5/2000 to 1/2002
Review and made adjustments for Debt Proposal and collection arrangement with insurance carriers and self-pay (Guarantor) payments for balances due.
Worked in the call center to resolve account problems and concerns for the patients, physicians and insurers.
Prepare adjustment sheets, reprocessed for denials and appeals as indicated by the Collections and Revenue Enhancement Division. Document the system activity.
Establish account payment arrangements and handled special processes.
Work with Utilization Review department on denied and appealed process as needed.
Perform the duties of a Patient Assessment Rep in the ER department (Registrar) on a part-time on call bases.
George Washington University Health Plan- Claims Specialist 5/1997 to 5/2000
Prepare claims for appropriate Medical ICD-9 and CPT coding input.
Process claims for payment to commercial insurance carries.
Investigate correspondences from coordination of benefits and reapply back to the insurance carriers to resolve claim payments issues.
Provide knowledge of claims preparation and adjudication for payment to staff members and other departments.
Value Behavioral Health Inc. - Quality Reviewer 6/1992 to 4/1997
Prepare comprehensive claims review report for weekly and monthly statistics.
Maintain accurate records of documentation of all errors identified during the review process.
Worked on trends and reoccurring problems to the claims processors and management staff.
Assisted in the quarterly audits and set procedures for quality standards within the department.
Experiences continue: Claims Team Leader 12/1991 to 6/1992
Supervised and coordinated all functions of reporting of staff issues and concerns.
Provided supervision on customer calls from the insurers, providers and facilities on current benefits and procedures problems based on their submitted claims.
Assist with reporting data relating to departmental goals. Created and policies and formats that set guidelines for claims functions.
Resolved complex payment issues from the Quality Review Unit.
American Psych Management- Claims Adjuster 10/1990 to 12/1991
Process all adjustments from payment errors.
Handle confidential client information in preparations for adjudication of claims process.
Ensure that the department set and follow the guidelines and procedures standards for all denied, appealed and resubmitted claims.
Experience continues- Claims Processor 4/1987 to 10/1990
Prepare psychiatric and or substance abuse CPT and ICD-9 coding to process.
Process psych and substance abuse claims to third party payers.
Provide assistance in training on claims payments and orientation of departmental functions.
References upon Request
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