Tabatha D. Rucker
Ruskin, FL *****
**/**/**-******* ********* Process Specialist (SME)
I handle inbound and outbound calls for a health insurance company Medicare Advantage plan for Alabama, Arizona, Colorado, New York, Ohio and Tennessee markets.
I assist team members with SME support as needed with both member and provider calls, claims, member premium payments and benefits, and I handle escalated calls when the supervisor is not available.
I’m part of the TriWiki team. TriWiki is a database used to document step by step processes and procedures on handling various calls an agent may get throughout the day. This database is reviewed, updated and or corrected as needed so that processes and procedures always remain up to date.
I’m responsible for working DMS (Document Management Systems) accounts daily in which the accounts have a 10-day turnaround/completion time frame. The documents may consist of various items pertaining to both member and provider issues.
11/15-03/17 Anthem, Inc. Claims Analyst ll
I processed new day and aged claims as they were loaded into the Macess and Facets data base.
I was responsible for building claims and then processing them for payment.
I sent out correspondence letters to the providers when additional information was needed to process their claims.
I transferred/pended information to the appropriate department as needed for further review.
I reviewed and or requested OHI (Other Health Insurance) information in order to coordinate benefits for proper payment of claims.
07/13 Volt/PS Temp Agency/WellCare & 11/13-11/15 WellCare Health Inc. Claims Specialist ll
I worked FMTs (Field Magic Tickets) projects and resolving hold codes issues.
Adjusting claims per the guidelines for that specific Market and LOB.
Corresponding to the provider's inquiry(s) concerning the status of a claim, dispute and or appeal.
Data Recon/ Check Tracers, void and reissue check requests.
Updating provider information such as addresses and verifying NPI numbers.
12/06 – 05/13 BCBSFL PCC-MCC TAMPA
Handled inbound and outbound calls giving benefits, eligibility, claims and appeal status for both members and providers.
Reached out to the appropriate departments as well as providers and collection agencies on the member’s behalf in an effort to resolve their issue on a first call basis.
I scheduled call backs within a 48hour timeframe for calls that were not resolved on the same day.
I worked written correspondence that came through electronically and/or via the postal service.
I offered SME support as needed to both new hires and seasoned advocates.
I worked the team’s aged pending queue so that the team would not fall behind and I offered backup Senior support when needed.
I handled Supervisor calls when advocates got escalated calls that demanded a supervisor’s attention.
I handled the voicemail for all member calls that came through the voicemail system overnight and I called the member back in hopes of resolving their issue.
11/05 – 10/06 Lincare Inc. Medicaid Collections Specialist:
Responsible for collecting money on aged accounts.
Answered patient’s calls with concerns about their account.
Worked aged accounts using an AR report and I also verified Medicaid eligibility.
I was responsible for getting authorizations and keeping them current for members to continue use with their Durable Medical Equipment.
I contacted insurance companies to check the status of claims.
4/04/-11/05 MP Total Care, Inc. Document Collection Specialist:
My responsibilities included collecting Physician Written Orders from the doctor’s office and making sure all information was in compliance with Medicare guideline.
Calling the provider’s office to ensure all documentation was correct and complete prior to having invoice transmitted for billing.
Worked aged reports to collect on payments before reaching the timely filing limit.
Trained new team members on processes and procedures pertaining to our department.
Was responsible for keeping team members up to date on any new changes in the department.
Finalized PWO’s, followed up on invalid documentations, worked End of Day (EOD) and renewals.
05/03-01/04 South Tampa Rehab & SNF Nurse’s Station Clerk:
I updated resident’s charts making sure all information was current
Took reports from the hospital on the resident’s condition (changes) prior to their return to the SNF.
Made all appointments and transportation arrangements for all office visits not on the SNF premises, also accompanied the residents to and from their appointments.
11/02-05/03 Maternity Leave
06/00-11/02 BCBS of FL Claims Specialist:
Responsible for researching customer claims for any discrepancies prior to being processed.
Answered member calls to verify their medical benefits.
Made physician changes per the member’s request.
Approved or denied claims according to member’s benefits plan.
04/98-08/99 Mariner Health of Tampa SNF Admissions Coordinator:
Collected and verified all documentation prior to admitting a resident into the facility.
Scheduled meetings with family members and gave tours of the facility.
Held daily meetings with Department Managers to give updates on new admissions, diet changes, physical/occupational therapy needs and any expires overnight (deceased).
Made calls to hospitals to check on the status of residents returning to the facility and get a report on any new residents being admitted.
Verified insurance and proper ICD 9-codes for the billing office.
Handled accounts payables and collected new data for the Daily Census Report to be submitted to the corporate office.
I am a team player and team leader with a genuine focus on every customer having a WOW experience.
Detail oriented with knowledge of Windows environment and front office equipment.
I am experienced in training and coaching others as well as public speaking.
Insurance verification and submitting Medicaid claims electronically.
I am knowledgeable of Medicare and Medicaid guidelines.
I am confident in handling both inbound and outbound calls.
I communicate well on all levels both verbally and written.
I bring to this organization experience as well as a willingness to learn with a desire to grow and a “Can do” attitude.
EDUCATION & TRAINING
ConCorde Career Inst. Medical Assistant
Ft. Lauderdale, FL
HCC Early Childhood Development
Ybor City, FL
Counselor Enrichment Training Course
Master Certificate 1999
H.I.T. (High Impact Training)