Customer Service Life Insurance

P O Box ******, Houston, TX *****

**************@*******.*** 713-***-****

Willie Ruth Oben

Objective

To continue employment with a company where my skills and experience will be an asset to the business while furthering my knowledge and abilities in the process.

Professional Experience

Claims Processor/Adjustor – Dell, Round Rock, TX ● 04/15-05/15

Researched and adjusted previous incorrectly paid Medicaid claims via Diamond System.

Knowledge of CPT, HCPC, ICD-9/10 Codes and medical terminology.

Self-starter with minimum supervision.

Claims Processor–Jacobson Solutions, Chicago, IL ● 10/14– 02/15

Processed claims for payment ensuring all information was supplied before eligible payments were made.

Researched and analyzed claim issues.

Processed all claim types such as COB, DME, special/manual pricing, and outpatient/inpatient claims with good working knowledge of grievances and/or appeals process.

Good understanding of the application of benefit contracts, pricing, processing, policies, procedures, and healthcare terminology.

Claims Manager–Amerigroup Community Care/WellPoint, Houston, TX ● 07/11-05/14

Monitored claims processing activities to ensure that the organization’s service, quality, productivity and financial standards or goals were achieved.

Conducted interviewing of potential candidates.

Provided proactive and on-going communication to designated internal customers regarding policies, procedures and systems issues through regularly scheduled meetings, and telephone calls arranged and/or presented by the incumbent or assigned resources.

Interpreted contract language and rates and coordinated with other internal customers to ensure the accuracy of system configuration and claims processing.

Provided timely and effective monthly performance reviews and counseling sessions with associates.

Tracked productivity and performance of individuals; completed monthly scorecards for assigned individuals.

Processed claims in order to meet TAT utilizing FACETS operating system.

Worked with Providers and Member Service staff to resolve problem situations raised through member or provider communication.

Conducted, facilitated, and actively participated in meetings.

Worked with claim teams and other functional areas to ensure resolution to issues and provide long-term solutions.

Provider Claims Resolution Rep–Amerigroup Community Care, Houston, TX ● 03/07-07/11

Investigated, reviewed, and resolved complex claims and appeals through interaction with providers and provider services staff in a timely manner.

Forwarded claims research and resolution to Claims Processing Department for payment reconsideration.

Knowledge of provider’s contract language, claims processing, ICD-9, Medicare and Medicaid guidelines.

Took initiative to address and correct root cause of errors in addition to providing technical assistance on claims to Provider Service Representatives.

Identified and monitored provider issues and concerns, recommend solutions, and communicated with other departments to resolve the issues.

Worked independently and use reference material to resolve claims related questions.

Performed user acceptance testing to ensure new contracts were loaded correctly and system modifications were accurate.

Performed claims and trend analysis, ensures supporting documentation was accurate and obtained necessary approvals to close out claim issues.

Answered inbound and/or outbound telephone inquiries from providers and assisted with other problem issues.

Strong communication skills, both written and verbal.

Provider Claims Resolution Rep.-Westaff/Amerigroup, Houston, TX ● 10/06-03/07

This was a temp to hire position. Job description same as above.

Claims Team Leader- GulfQuest, L.P., Houston, TX ● 01/06 – 10/06

Managed medical claims processing to ensure claims were screened, researched, and paid in a timely and accurate manner.

Provided management staff with daily performance reports concerning claims payment of each examiner via excel spreadsheets.

Distribution of claims to 16 examiners via paper and electronic claims.

Trained examiners in procedures for claims payment and to ensure productivity standards were met.

Demonstrated an active interest in improving current level of skill and knowledge by regularly reviewing policy and procedure manuals.

Life Claims Analyst-American Capitol Insurance Company, Houston, TX ● 07/04-01/06

Responsible for adjudicating life insurance claims for payment with the use of accurate procedure.

Analyzed and researched each claim for correct payable benefits.

Corresponded with the correct beneficiaries and facilities; insuring the correct documents were submitted for payment.

Adhered to the standard turnaround time for completion of each task.

Excellent customer service with “people” skills.

Great organizational skills and detail oriented.

Claims Supervisor-Affiliated Healthcare, Inc., Houston, TX ● 09/96-06/01

Supervised, planned, organized, and monitored mailroom, receptionist, file/fax clerk, claims data entry and claims processing activities. Coordinated scheduling and work assignments to ensure quantity, quality and timeliness of data entry and claims processing production. Adhered to company policies and procedures.

Utilized strong “people” skills to monitor performance, train, develop and evaluate 22 employees.

Created effective team concepts, implementing rewards and delivering praise for a job well done.

Researched and identified customer service, system and employee problems by using a proactive approach to provide a resolution.

Developed detailed documentation for weekly and monthly production reports.

Department won the President’s Award for savings to the company, initiating teamwork and personal pride.

Programming and Software Skills

User Acceptance Testing Certified, MCS, Facets, Amysis, Macess, Diamond, Microsoft Word, Excel, Outlook, Power Point, and Access

Education

Tougaloo College, Tougaloo, MS ● Business Administration ● 09/76-05/78

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