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Medical Customer Service

Location:
College Park, MD
Posted:
October 04, 2018

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Resume:

Educational Commission for Foreign Medical Graduates board certified physician with over 10 years of experience in clinical and health program management, I have a demonstrated experience in project management, strategic partnerships building, and proven ability to work independently, as well as a team member. I am able to multi-task and produce measurable results with the leadership ability to inspire others and solve problems using proficient analytical skills and cross-sectoral strategies.

Professional Experience

2017 HEDIS review nurse : United Healthcare

Responsible for reviewing and abstracting medical records for the annual HEDIS project. The HEDIS review nurse

Documents all HEDIS related items into software on a daily basis.

Reviews and integrates medical information from electronic and paper medical records in a timely manner.

Participates in medical record collection, requests and abstracts appropriate medical records, assessing for assigned categories as needed.

Reviews assigned medical records in order to abstract specified and required clinical data elements for HEDIS reporting.

2016 Claim Examiner Conifer Health Solutions

Resolved medical claims by approving or denying documentation; calculating benefit due; initiating payment or composing denial letter.

Ensured legal compliance by following company policies, procedures, guidelines, as well as state and federal insurance regulations.

Examined claims investigated by insurance adjusters, further investigating questionable claims to determine whether to authorize payments.

Verified and analyzed data used in settling claims to ensure that claims are valid and that settlements are made according to company practices and procedures.

Knowledge of healthcare Common Procedure Coding Systems, ICD9/10, CPT codes.

2014-2015Senior Clinical Reviewer – Mobile X USA

I reviewed and audited medical records for completeness and accuracy by looking at various pieces of documentation.

Complete quality, accurate and inter-rater reliability testing as requested in a timely manner.

Conducted follow-up of cases to ensure the record is up to compliance.

Participated in all ongoing quality insurance projects.

Accurately and efficiently conduct medically record review/abstraction services..

Independently reviewed and made recommendation on retrospective appeal cases from STCH and SNF vendors.

Knowledge of software programs including proficiency in Microsoft word, Excel, power point.

Experience in use of Electronic Health Records for clinical documentation.

2012- 2014 Senior Medical Analyst-ADVANTA MEDICAL SOLUTIONS.

I reviewed and analyzed medical claim reports for medical necessity and appropriateness of medical care and/or level of services in applying established and/or recommended criteria tools including InterQual clinical criteria, Milliman Care, and Cimro of Nebraska Guidelines.

Audited claim charges to accurately identify inappropriate and disallowed charges as defined by centers for Medicare and Medicaid (CMS) guidelines.

Identified and referred all cases not meeting medical necessity criteria and guidelines to the Medical Director for evaluation. Documented clinical review summaries, bills, audit findings, and audit details in the database.

Participated and Provided input during quality assurance process and the documentation of best practices.

2012 Externship Physician Associates, Maryland

As board certified EFMG, I was shadowed Doctor Elliot Goldstein and several other Internal Medicine physicians during their rounds.

I independently initiated clinical assessment of the patients, developed and recommended the care and treatment plan to the attending. I actively participated in clinical cases discussion, treatment options and discharge planning.

Provided health education and disease prevention sessions to the clinic patients and insured that they have clearly understood their treatment plan, prescriptions administration, and follow up appointment as needed.

Explain procedures and discuss test results with patients and Advise patients and community members concerning diet, activity, hygiene, and disease prevention.

2011 - 2012 Direct Patient Care Associate-Compass Inc, Maryland

Performed all assigned duties in accordance with established policies and procedures, safety rules and regulations

Assisted residents with activities of daily living (ADLs) including but not limited to: bathing, dressing, grooming, and shaving male residents when needed

Encouraged residents to perform ADL’s that they are capable of including assisting residents to meals and supervised residents in dining rooms.

Prepared residents for rest, physician visits, therapy, activities, church, transported and, assisted residents with these activities as needed.

Performed personal services for residents within reason such as reading to them, operating TV and radio, and assisting them with recreational and therapy projects in their rooms.

2010-2011Quality Assurance Supervisor- Premier Home Health Care, Washington

Supported the implementation of client’s care-plan.

Routinely tracked customer satisfaction and developed strategies for customer retention.

Project management skills and demonstrated experience.

Provided for a safe living environment for client without infringing on the clients rights.

Regularly updated the facility manual of operations procedures and ensured that the staff adhere and are compliant with the company policies and procedure.

2005- 2010 Quality Assurance Supervisor-Dynamic Visions Home Health Agency, Washington

Responsible for the overall day-to-day operational management of the quality of care provided to clients;

Ensure excellent customer service are provided to clients;

Managed the business supply system and ensured timely and adequate procurement of the needed supply;

Routinely tracked customer satisfaction and developed strategies for costumer retention;

Recruited and retained talented staff and kept accurate staff files

2000 - 2004 Emergency Attending Physician-Centre hospitalier Universitaire de Charleroi, Belgium.

Treated patients presenting in the ER and ensured proper injury care and disease diagnosis, treatment, and recovery.

Requested necessary tests and follow up visits and referred patient to the appropriate specialists as needed.

As part of the emergency resuscitation team, attended to all code bleu and emergency cardiovascular resuscitations in the hospital.

Trained to work quickly and effectively even with minimal information, I was involved in the rounds of urgent Medical aid service(SAMU) and participated in the development of contingency plans for citywide disasters or mass causalities.

1999 - 2000 Attending Physician Internal Medicine-Centre Hospitalier Universitaire de MONS, Belgium

Caring and treated for hospitalized patients on the medical floor for internal disorders, such as hypertension, heart disease, diabetes, and problems of the lung, brain, kidney, and gastrointestinal tract.

Analyze records, reports, test results, or examination information to diagnose medical condition of patient and prescribed or administered medication, therapy, and other specialized medical care to treat or prevent illness, disease, or injury and monitor patients' conditions and progress and reevaluate treatments as necessary.

Directed and coordinated activities of nurses, students, assistants, specialists, therapists, and other medical staff.

Refer patient to medical specialist or other practitioner when necessary and Provide consulting services to other doctors caring for patients with special or difficult problems.

Volunteer Experience

2011 - 2012 Medical Assistant-Doctor's Office, Maryland

Completely filled out labs slips and other forms when necessary.

Noted brief history or the reason for visit in patient's chart.

Prepared patient for examination.

Administered medications and injections when necessary. Measured patient's vital signs.

Performed blood draws, EKGS. Counseled patients by transmitting physician's orders and questions about surgery.

Education

09/1994 - 06/1999 Université Catholique de Louvain Faculté de Médecine et Médecine Dentaire, Belgium ( Bachelor degree)

06/1990 - 09/1994 Faculté Universitaires Notre-Dame de la Paix (FUNDP) Faculté de Médecine, Belgium (Doctorate in medicine)

Certification/Licensure

Board Certification: ECFMG

09/2001 - 06/2002 M.D. Fellowship-DES en Medicine Aigue, Brussels, Belgium

Critical Care Medicine (Internal Medicine)

Language Fluency :

English (Good)

French (Native)



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