Customer Service Medical
Resume:
La’Shonda N. Gordon
**** *’Neal Ln
Baton Rouge, LA 70816
**************@*****.***
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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