Service Representative Manager
Resume:
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.
Contact this candidate