Customer Service Insurance

*** ****** **** ** *** G* SW, Riverdale, GA 617-***-**** ******.*********@*****.***

LaToya Gardner CPhT

Computer, and Other Professional Skills

Microsoft Office, Unicare Skilled in Medicare, Medicaid, and Workers Comp claims

Meditech, IDX, Dentrix Medical Billing & Coding, research skills

Facets, Onbase, MMIS Matrix Experience with Commercial insurances including BCBS, Medical Transcription Athena, Aetna, United Health Care, Unicare

MMIS, Matrix, and AS400 Admissions, Medical records, and behavioral health

Professional Accomplishments

Admissions Staff

Interact effectively with inebriated, uncooperative, and emotional disturbed people seeking treatment services through the Tier and Hill Software systems for detox, (DDU) Dual Diagnosis, and (IPU) Inpatient psychiatric unit.

Reviewed applicable legal and medical documentations from hospitals, crisis centers, and court systems (Section 35) to make appropriate decisions to find better placement for the patients. Maintained confidential files using wide variety of filing and recording systems. Update the census regularly. Verified insurance coverage.

Interviewed social workers, and patients to ascertain, and identify unknown medical problems, if there were history of psychiatric diagnosis, suicidal, and homicidal ideations, suicide attempts, self-injurious behaviors, suboxone/ methadone maintenance, blackouts, DT’s, drug choice, the amount used, pattern used, and if he/she is currently on any medications.

Admissions Coordinator/ Central Admissions

Communicate with hospital case managers by phone, and through computer software’s E-Discharge, 4NEXT, and All Scripts. Researched new patient’s referrals to see if they are appropriate for Short term, and long term care. Verifying if the patients have a skillable need.

Worked closely with nursing. Prepared the charts and getting the necessary paperwork such as discharge documents for the hospital, screens from the nurse liaisons, factsheets, HCP, guardianship, 30/60 day forms, and level of care. Admit, transfer, discharge patients in RMS, as appropriate. Prepare identification records/ medical records for residents, bed management, send out bed availability daily, order the necessary supplies such as bariatric beds, oxygen supplies, and wound vac through ISIS, and KCI.

Interviewed residents, and responsible parties on the phone, in person to obtain the required information. Signed, and completed admissions paperwork, explaining the billing procedures, insurance coverage, visitors/ guest, privileges, restrictions, and resident care.

Customer Service Specialist

Preformed quality assurance through automated, and telephone inquiries to verify insurance claims, workers comp claims, and auto insurance claims for the child support lien network project. Created, and sent computer-generated documents, generated e-mails, excel spreadsheets, making sure the procedures were followed accurately. Communicated with Child Support divisions in 33 States to make sure and the proper child support liens were sent out in a timely manner, and to make sure the insurance companies were sending out the payments properly.

Provided professional and courteous customer service support to public and private network members.

Set up new registrations for insurances companies, and attorneys on the Child Support Lien Network website. Directed families to the proper departments for assistance.

3rd Party Claims processor

Investigated information to ensure accurate processing, and to resolve all discrepancies with purchasing associates, pharmacists, DON’s, and nurses, other potential issues, and denied claims prior to medication delivery.

Ensure approval of claims by preforming reverses on edits discovered through the filing process. Completed necessary authorization forms (CMS, Prior Authorizations, etc.) to ensure appeals are handled effectively. Requesting overrides for 1st time fill of medications.

Worked with Commercial insurance companies such as BCBS, United Health Care, Unicare, and Medicare/ Medicaid, nursing facilities, and family members to minimize loss of non-reimbursed inventory; Follow-up with nursing staff as needed.

Employment History

5/2015-Present

Admissions Staff

High Point Treatment Hospital, Middleboro, MA

11/2014-Present

Admissions Coordinator/ Central Admissions

The Royal Health Group, Buzzards Bay, MA

1/2014-7/2014

Customer Service Specialist

Stellaware-Child Support Lien Network, Holbrook, MA

3/2013-1/2014

3rd Party Claims Processor

PharMerica, Brockton, MA

Education

2013

2013

2004

1998

Pharmacy Tech Diploma

Pharmacy Tech Externship

Administrative Assistant/ Medical Billing & Coding

Environmental Justice course

Sanford-Brown, Cranston, RI

Walgreens, Johnston, RI

Lincoln Tech, Somerville, MA

Tufts University, Boston, MA

References

References are available on request.

Contact this candidate