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Customer Service Medical

Rex, GA
September 21, 2018

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**** *. ****, *******, ** ***** ♦ C: 678-***-**** ♦ PROFESSIONAL SUMMARY

Dedicated, results-oriented Professional with 10+ years of total experience in sales, healthcare compliance, and customer service. Proven capability to interact and negotiate with clients, collaborate in team settings, and provide subject matter expertise. Success in achieving multiple objectives in high-volume, high-pressure and remote environments while adhering to relevant policies and procedures.

Medical Billing & Coding Regulations Compliance

Verbal & Written Expertise Communication & Client Interface Documentation & Assessment Coordination & Teamwork Planning & Organization


Remote Experience

Administrative Support & Customer Service Technical Proficiency

Denials, Appeals, & Claims

ICD-10 Coding

Accounting Principles

MS Word & Sharepoint



Evaluate claim grievance for reconsideration and approve or deny based on determination level. Investigate if claim grievance includes potential quality or access issue and prepare cases for medical review as necessary. Resolve all State inquires by acting as subject expert regarding grievances and appeals, mber, provider regulatory agencies, and internal staff.

Coordinate with key individuals and specialists, utilizing advanced interpretations to resolve complex cases. Analyze and resolve verbal and written claims and authorization grievance and appeals from providers and members. Liase between member, provider regulatory agencies, and internal staff.

Review and process member and provider grievances and appeals within federal, state and organizational regulations and policies and procedures.

ASSOCIATE II MEMBER SERVICES (REMOTE), 09/2014 to 08/2017 Kaiser Permanente

Professionally interfaced with callers, providing quality assistance and resolution. Oversaw difficult callers with compassion and patience, while escalating when necessary.

Served as claims payment expert, explaining information on receipts, eligibility, benefits, delivery system services, payment quantities, deadlines, and authorization status.

Remained updated on claims processing guidelines and health plan benefits by studying literature, staying aware of trends, and participating in workshops. Conducted research for root cause analysis and reporting trends. Interacted, collaborated, and negotiated across all organizational levels. Attended meetings to enhance departmental performance.

Recorded phone calls and collected data. Applied various statistical techniques to analyze individual and call center performance, independently providing recommendations for process improvement and service recovery. Supported internal customers with special projects and studies to optimize service.

Mastered knowledge of relevant medical terminology, CPT, and ICD-9 coding.

APPEALS COORDINATOR, 01/2012 to 12/2013 United Health Care

Provided expertise or general claims support by reviewing, negotiating, and adjusting claims.

Responded to provider phone calls and correspondences, including claim adjustment requests, appeals, corrected claims, timely filings, and claims projects. Managed complex clinical appeals such as transplants.

Researched, collaborated, and triaged all types of appeals and grievances. Identified and analyzed trends, overseeing coordination and collection of all information and presentation to Medical Director/Appeals Committee. Evaluated and approved member eligibility and benefits by investigating member information such as authorizations, payments, denials, and coordination of benefits. Collected case review documentation, analyzing if physician review is required and preparing written responses.

Coordinated outside physician clinical reviews, including with Health Services to obtain clinical information. Documented receipt of appeals and conducted timeline tracking to ensure responses within timeframe.

Prioritized tasks to consistently adhere to HIPAA regulations, Georgia Medicaid and Medicare regulations, and industry standards for claims adjudication.

Mastered knowledge concerning UHC benefits, provider network development and contract issues, and other party liability issues. Familiarized with CPT-4, ICD9, and HCPCS coding.

FRONT DESK COORDINATOR, 02/2011 to 12/2012 Peachtree Orthopaedics

Greeted patients and visitors in prompt, courteous, and helpful manner. Answered incoming calls, maintained waiting area, screened visitors, and provided routing request information.

Checked in patients, verified and updated information, and reported issues to Registration Coordinator. Assisted patients with ambulatory difficulties.

Prepared patient electronic-charts with new patient documentation and updated information for established patients. Gathered workers' compensation information and appropriate forms, monitoring and reporting unscanned or missing intake forms.

Handled patient checkout, collected copays, and reconciled daily receivables. Documented daily collection sheet of copays and totals cash, checks, credit cards.

Updated physician schedules and scheduled patient appointments.

Supported front desk, medical assistants, physician assistants, and other staff with miscellaneous task.

CUSTOMER SERVICE REPRESENTATIVE, 05/2010 to 02/2011 SRTA-State Road and Toll Authority

Resolved inquiries related to agency programs and operations.

Generated Clerk detail and toll violation reconciliation batch reports.

Provided technical assistance and oversight to other customer service agents.

Applied accounting principles to compute total available funds for balancing and to enter payment information for debits and credits.

SALES & MARKETING ASSISTANT, 09/2007 to 2009 USTeleradiology Atlanta, GA

Monitored and matched patient images with orders. Verified image counts and entered fax order data. Coordinated physician conference calls. Conducted outbound calls requesting missing images, orders, worksheets, or additional requested data.

Provided documentation for studies and projects. Identified and troubleshot issues and mismatched studies.


Clayton State University -

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