Medical Customer Service

Virginia Rivera

***** ***** ****** **, ****** Texas 75035

972-***-**** ********.******.******@*****.***

HIGHLIGHTS

Knowledge of medical terminology and medical billing codes Attention to detail and thorough note taking

Determined if the policy of the insured covers the loss claimed EXPERIENCE

Process individual major medical claims using the EDS Processor I Claims System. Process professional and hospital medical claims using QcareWe for Emblem Health Supervision of fourteen employees performing various duties in the file department. WORK HISTORY

The Reny Company August 2017 to July 2018

Plano, TX

Pre-Screener Responsible: for verifying bill has been keyed correctly

* Prescreen claims for accuracy and efficiency of the daily workflow

* Ensured correct bill processing in line with State Fee Schedules and guidelines

* Determine validity and compensability by verify the information regarding the claim

* Knowledgeable of Word, Outlook, and SmartAdvisor Main System Dell Service Center April 2009 to December 2016

Plano, TX

Sr. Claims Examiner Responsible: for any data entries errors, coding errors and claim issues

* Process professional and hospital claims

* Process Medicare and Medicaid claims

* Process Claims using QcareWe system

* Met individual and department standards with regards to quality and productivity goals

Medical Claims Resource Inc. May 2004 to 2008

Dallas, TX

Team Lead and PPO Repricer Responsible: Training other re-pricers and phone for customer service

*Sort Claims from Clients through nine PPO providers by TID and/or Provider Name

*Match, reprice, print the repricing sheet and invoice the client

*Make and answer phone calls to and from providers to gather additional information needed to reprice the claim

UICI The Mega Life & Health Ins. Co. November 1994 to April 2004 North Richland Hills, TX

Claims Examiner: Responsible: For coding errors and claim issue

* Process Medical and Health claims

* Process Claims using EDI system

* Reach out to other departments to make corrections and policyholders issues National Financial Insurance Company (aka Reserve Life Insurance Company) Dallas, Texas September 1987 to July 1994

Senior Claims Examiner Responsible: For the insured eligibility, policies and procedures

*Process individual major medical claims

*Understanding of coverage interpretation

*Reach out to other departments for corrections and policyholders issue Education

LOMA

High School Diploma, Bryan Adams High school, Dallas, Texas

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