Phone # 305-***-****
To obtain a position with a growing company where I could utilize my skills to the best of my ability.
SUMMARY OF QUALIFICATIONS:
I am oriented self-motivated professional, having 15 years of diversified experience in the managed care industry. In my years of experience as a member service specialist I have developed a great rapport with members and providers of care alike:
My skills experiences include:
* Coordinating care and services for members.
* Interface with primary care physicians and staff.
* Serving as liaison between the members and the company.
* Coordinating referrals with specialist and hospitals, resulting in retaining happy members in the health plan.
2012-2017 Sheridan Healthcare Corp. Sunrise, FL
ED Reimbursement Specialist III
● Run reports on specific providers or insurance that may have an outstanding AR over 30/60 or 90 days pending any payments and no response from insurance company.
● I would also ensure my team was update with their correspondence or their grid
● Adjust any accounts if necessary
● if any payments were posted incorrectly forward them to the payment posting department to have the correction made.
● Have weekly huddled with the team to inquire if they had gathered any new information pertaining a payor, any new issues, discrepancies
● Biweekly meetings with management to discuss any new issue update on A/R
● Researches all assigned contracted and/or non-contracted carrier and self-pay accounts to ensure the proper payment through reports, spreadsheets and special projects as deemed necessary.
● Processes correspondence related to assigned contracted and/or non-contracted carriers including self-pay accounts.
● Maintains denial reports and ensures accounts are properly documented.
● Responds to customer service calls and strives for one time resolution of accounts received.
● Researches denied and improperly processed claims by contacting assigned carriers to ensure proper processing of said claims.
● Resubmits improperly paid/denied claims to the carrier for proper payment in a timely manner.
● Identifies and corrects any claim processing errors due to data entry, verification, coding and/or posting mistakes. Ensures accounts are properly documented.
● Call and check claim status, work A/R and insurance carrier reports, and insurance denials
● Handle and organize all aspects of the appeals process for all insurance payers
(letters, phone calls, special projects from carriers).
● Interface with front office staff regarding insurance/patient issues 2008- 2012 American Ambulance Miami, FL
* Document the denial's the insurance companies send for the patients
* Appeal the denial's
* Correct the claims and resubmit them
* I am in charge of the Treasure Coast Region and I handle all the Insurances Blue Cross, Cigna, United Health Care, Care Plus, Staywell, Well Care, Medicaid, Magna Care, Aetna,
* Customer Service
* Answer the patient's questions pertaining their claim
* Explain to the patients how they may appeal a claim
* Verify coverage for the patients thru Emdeon or Availity also contacted the facilities or the patients for information
2007-2007 MD Medicare Choice/ Partner Care Health Doral, FL Enrollment Specialist
* Received new Medicare applications on a daily basis
* Reviewed applications to make sure they were completely filled
* Reviewed information in the CMS system before entering
* Enter applications in the system
* Forward all original applications to the Corporate office via Fed Ex on a daily basis
* File copy of the applications
* Planning and forecasting short and long term objects
* Set up daily and weekly visits for participating providers
* Maintained daily contact with the assigned physicians
* Weekly staffing with marketing supervisor for updates on all marketing activities
* Insure that all marketing materials are in place at the providers office
* Responsible of development for the marketing
2005-2007 Sun Coast Health Plan Weston, FL
Provider Relations Supervisor
* Maintained and coordinated timely communication between the providers and the health plan by routinely meeting and communicating with providers and their office staff
* Ensured that all network providers understood the health plan's policies, procedures, and contractual obligations
* Established and promoted provider satisfaction by maintaining an open exchange of information by soliciting provider feedback for continued quality improvement and retention of network providers
* Resolved provider/member complaints, claims issues, and grievances in a timely manner
* Collected necessary information(i.e., site visit form, re-credentialing applications, supporting documents, etc.) as requested by the Credentialing department
Customer Service Supervisor
* Supervise a staff of Customer Service Representatives to ensure prompt responses to member inquires and complaints
* Delegate, plan, and organize duties of Customer Service staff
* Confirm process flow is followed and is within CMS guidelines
* Oversee enrollment and disenrollment processes
* Contribute to the going integration of Customer Service by identifying opportunities for quality and process improvements 2003-2005 Vista Health Plan Hollywood, FL
Special Service Representative
* Retained members on the plan
* Welcomed members to the plan
* Contacted members to participate in orientations as well as set up location, dates and plans for large events throughout Southern Florida 2001-2003 Care Plus Health Plans/Physicians Healthcare Coral Gables, FL Customer Service
* At Care Plus Health my duties were to service the members with changing their primary physicians at their request. Assisted patients with choosing a healthcare specialist and resolving referral issues. In addition, I provided members, providers’, hospitals, pharmacies and skilled nursing facilities with eligibility and benefits.
1999-2001 Americatel Corporation Doral, FL
Customer Service Specialist
* At Americatel, my duties included effectively monitoring trouble tickets from Americatel clients for V-SAT, IBS & Internet Services. Also, provided efficient maintenance support for private code such as 1010123. I worked as a team player while troubleshooting, monitoring discrepancies within Americatel fraud department.
1991-1998 CAC Ramsay
Receptionist/Cashier Miami Lakes, FL
* At CAC Ramsay my responsibilities were to greet the patient, answer the phone, schedule appointments and medical records. I was also responsible to receive the monthly premium payment and also receive the co-payments of the patients. I also worked in the medical records and referral department.
2005 Florida Career College Hialeah, Fl.
* Completed Medical Billing & Coding Program