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Customer Service Medical

Location:
Baton Rouge, LA
Salary:
50,000
Posted:
March 31, 2019

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Resume:

La’Shonda N. Gordon

**** *’Neal Ln

Baton Rouge, LA 70816

321-***-****

ac8ymd@r.postjobfree.com

QUALIFICATIONS SUMMARY

Mastered Excellent Written and Verbal Communication proficiency within the Healthcare Industry. Conflict Management and Counseling expertise attributed to ability to resolving wide array of diverse and complex situations while ensuring compliance. Committed to Excellence through providing quality customer service equating to repeat business and above average customer feedback

EDUCATION

Woodlawn High – High Diploma August 1998 - May 2002

Newspaper Columnist (poetry), Active in school choir

University of Phoenix – A.A. Mass Communications June 2008 - March 2011

PROFESSIONAL EXPERIENCE

University of New Orleans July 2018-Present

Louisiana Department of Health

Chisholm Compliance Coordinator

Assist the Chisholm Compliance Officer in monitoring 3 MCOs for compliance with all Chisholm Orders and Stipulations

Daily look for new PA’s for Extended Home Health and EPSTD Personal Care Services.

Analyze each PA to ensure that the notice meets all Chisholm requirements and communicate any issues with that notice to the MCO, Molina and the Chisholm Compliance Officer

Determine if the case was Chronic Needs. o Determine if the member was previously approved to receive the service by Molina or another MCO

Other tasks as directed

Ameri-Health Caritas, Louisiana Dec 2015 thru June 2018

Provider Network Analyst Operations

Assist the Account Executives with updating provider’s profiles to ensure claims are processed under compliance guidelines with correct ICD-10 codes

Multitasking – collecting, processing data while responding to questions, resolving concerns, providing guidance on transactions, inquiries along with complaints from both internal and external customers.

Work on provider claims issues and projects to reprocess hospitals split claims which required the ability to be able to correct codes and advise the provider of the correct revenue codes to obtain the correct payment amount.

Utilized time management to ensure that health plan roster validations and attestations are accurate and complete along with analyzing any updates to provider using the companies Operational System (EXP).

Receiving and sorting mail by documenting any certified mail that comes in.

Frazee Recruiting April 2014 - December 2014

Intake Coordinator with Blue Cross Blue Shield of Louisiana

Handle an average of 90 inbound calls daily assisting member and medical health facilities with general questions and obtaining preauthorization’s for various procedures.

Created profiles to ensure patient insurance information is valid and up to date.

Settled customer disputes and interpreted diagnosis codes referred to ICD9 and provide direction on how to submit appeal on denials.

Med Solutions, Melbourne, FL September 2011 - November 2013

Intake Representative

Handle an average of 90 inbound calls daily s assisting members and medical facilities with general questions and obtaining preauthorization’s for various insurance companies.

Created profiles to ensure patient insurance information is valid and up to date

Settled member disputes and interpreted diagnosis codes referred to ICD9 and provide direction on how to submit appeal on denials

BlueCross BlueShield, Baton Rouge, LA May 2010 - August 2011

ITS Provider Advisor

Answered general questions from healthcare providers regarding out of state insurance claims. Utilized ITS adjustments to adjust any claims that paid incorrectly. Worked on daily log to correct any additional issues with claims that were not processed in a timely manner.

Partnered with Blue Cross personnel regarding status updates to ensure all pertinent information is acquired to process claims within allotted time

Managed multiple systems to query information necessary to ensure information was up to date and contacted health care providers to mitigate incorrectly submitted or missing information

Imaging Clerk November 2007 - May 2010

Sorted, batched, and scanned claims and member enrollment forms for electronic copy storage using scanners

and specialized photocopy equipment

Reviewed micro film adjusted angles and exposures of medical documents to generate clear and legible

pictures, images, and text to guarantee efficient records processing submitted by providers.

Maintained logs of daily activities and tasks, accessed archived images and files

TECHNICAL SKILLS

Appian

BPO

Facets

IBM Host –Extra

Jiva Systems

Microsoft Office (Word, Excel, PowerPoint and Abstraction)

Medical Terminology

Outlook Email

SharePoint

Streamline

Triage

Type 60 wpm

Visual Cactus



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