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Service Representative Manager

Location:
United States
Posted:
April 26, 2014

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Resume:

**** ********* 727-***-****

Court Apt *** E-mail

Palm Harbor, FL hildacollazo@yaho

***** *.***

Hilda Collazo

Objective A position in which my experience, high level of

motivation and interest to succeed can be used to make

a contribution to your company while at the same time

enhancing my present skills.

Experience

September 2010-Present IkaSystems, Southborough, MA

Implementation Support Manager/Senior Product

Specialist

Analyzes, develops/designs configuration

requirements/specifications, configures/implements, and

maintains in accordance with the customer needs.

Develops and maintains system configuration in

accordance with clients needs. Research complex

problems to ascertain possible solutions. Design and

implement solutions to support key business objectives,

including developing design requirements and technical

specifications. Train users in System application and

configuration. Serve as Medicare Subject Matter Expert

on benefits and Medicare reimbursement. Work with Third

Party Vendor OptumInsight managing inquiries impacting

Easy Pricer and Claims Editing (CES) software and

resolving pricing issues with Medicare Advantage LOB

Clients. Review Product release documentation and

coordinate deployment in Claims Platform environments.

Design and execute test plans, tracking defects and

getting them resolved to ensure that business

requirements and functional specifications are tested

and fulfilled.

April 2007 - September 2010 HMS of America Tampa, Fl.

Claims Supervisor/ Claims Manager

Coordinate and assign work for claim staff. Audit

processed claims for accuracy. Research, process and

adjust claims referred as priority by others

departments. Research Medicare guidelines and

regulations for properly adjudication of claims.

Interview and screen job applicants and make hiring

decisions .Responsible of training for new employees.

Monitor and coach on all claims errors. Interact with

other departments to resolve problems rose through

member or provider communication.

February 2006 - April 2007 Wakely and Associates

Largo, Fl.

Claims Examiner

Analyze claims to determine the extend of insurance

carrier liability. Interpret contract benefits in

accordance with specific claims processing guidelines.

Receive, organize and daily use of information

regarding benefits, contracts coverage and policy

decisions. Coordinate daily workflow to coincide with

check cycle days to meet all service guarantees. Call

providers and policy holders as needed to properly

adjudicate claims. Research and review medical records

for policy rescission process.

September 2005 - January 2006 SafeGuard Dental & Vision

Tampa, Fl.

Member Service Representative

Answer inbounds call from members, agents, clients and

providers regarding the plans coverage, claims,

payments, insurance benefits, and eligibility and

providers locations. Assist members with choosing

providers. Place outgoing calls as needed to satisfy

inquiries that needed additional research.

May 2005 - September 2005 Option HealthCare Network

Bayamon, P.R.

Provider Service Representative

Made contact with providers such as primary physicians,

specialist, sub-specialist, dentists, clinical

laboratories and radiology centers for network

contracting.

Visit provider's offices for presentation of the health

plan, fee rates, billing process, etc.

Review signed contracts and completeness of credential

documents.

Provide information about subscriber's coverage,

benefits, eligibility and claims status.

July 2004 - April 2005 Preferred Medicare Choice

Rio Piedras, P.R.

Member Service Representative

Provide information of PMC Medicare Advantage products,

eligibility, benefits and coverage to beneficiaries and

providers. Fill reimbursement request forms and refer

documentation to the Medical Affairs Department for

services that requires authorization. Receive and

deposit premiums payment. Manage petty- cash and

general operation of Manati Regional Office.

June 2003 - June 2004 MCS Inc. Hato Rey,

P.R.

Costumer Service Representative

Provide information to subscribers, human resources

representatives and providers about eligibility,

benefits, coverage and claims status.

Prepared coverage certification letters.

Refer claims for payment, analyze denied claims and

refer to adjustment.

March 2003 - May 2003 COSVI

Rio Piedras, P.R.

Claims Analyst

Entry, process and adjust claims.

1992 - 1996 Medicare- Triple S Inc.

San Juan, P.R.

Providers Relation Representative

Offer information of rules, regulations and medical

claims to Medicare providers. Give group training to

new providers about the Medicare Program and billing

process.

1990 - 1992 Medicare - Triple S

Inc. San Juan, P.R.

Claims Auditor

Inquire research and analyze medical claims in order to

compute overpayments. Investigation of frauds claims.

Interpretation of CMS regulations to resolve

beneficiaries' complaints.

Education 1983-1984 University of Puerto Rico

R o Piedras, P.R.

27 credits approved to Master degree in Hispanics

Studies.

1977-1982 University of Puerto Rico

R o Piedras, P.R

BA in Psychology

Minor in Hispanic Studies.

Relevant Skills Bilingual

Knowledge in Word and Excel

Excellence in writing and oral communication

Knowledge in medical and dental terminology

Experience reviewing medical records

Knowledge in CPT, ICD Codes, HCPCS,DRG and APC codes

Familiar with CMS 1500 and UB-04

Strong presentation skills and

analytical/problem-solving skills

Reference Will be available upon request.



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