Customer Service Insurance

Hernandez

210-***-**** ****.*********@*****.***

EDUCATION: Coastal Bend College. Associate In Science Degree. 05/18/1999.

BACKGROUND/EXPERIENCE desired: Banks or Insurance Claims.

Strong computer navigational skills.

Experience in a production based environment with an emphasis on quality outcomes.

BANK SKILLS:

General Business/Maximizing Work Practices.

Service/Handling Service Challenges.

Service/Providing Solutions to Constituent Needs.

CUSTOMER SERVICE EXPERIENCE:

Billing and Coding Expertise:

High level of proficiency with multiple applications, including, but not limited to,

MS Office applications, Outlook, Word, Excel, and Power Point.

ICD 9 coding, CPT 4 Coding, Regulations, Outpatient/Inpatient Facility Coding.

Medical Claims Specialist Examiner Skills and Qualifications:

Experience using Windows, MS Office Suite, Excel, Email, Data Entry, Database.

Perform follow up with insurance companies on unpaid Medicaid/Medicare

insurance accounts and makes adjustments accordingly. (I.E. United Health, Blue

Cross Blue Shield, Tricare, Avesis and other small contract entities).

Ability to examine documents for accuracy and completeness.

Claims Adjustment, Financial Software, Documentation Skills, Data Entry Skills, Analyzing

Information, Problem Solving, Verbal Communication, Customer Focus, FDA Health Regulations,

General Math Skills, Statistical Analysis.

Claims Processing Specialist position requires a high level of attention to detail, organizational

skills, and comfort with multi-tasking. The successful candidate will demonstrate excellent

telephone and people skills, confidentiality, resourcefulness, patience, objectivity, an inquisitive

mind, and will not easily be intimidated. Must be goal driven and possess the ability to deal with

time sensitive projects and determine priorities.

Maintains strictest confidentiality in regards to client information.

Effective verbal and written communication skills.

Ability to take initiative and work independently.

Employment History:

Burnett Specialists. 901 NE Loop 410 Suite 320 San Antonio, Texas 78209.

Program Coordinator (01/01/2015-03/28/2015).

Creative, strategic and analytical thinker with the ability to manage multiple projects.

Knowledge of Microsoft Office and Windows based computer application and database

management.

Create authorizations for PAS, ERS, and Adult Day Care.

Enter diagnosis codes/procedure codes.

Initiate authorization requests for outpatient/inpatient services.

Verify eligibility and benefits.

Answer phone calls from different agencies and or members.

Process faxes through Cues within establish standards.

Macy's Retail Store. 6909 N. Loop 1604 East San Antonio, Texas 78247. 210-***-****.

Recovery Specialist (11/01/2015-12/31/2015).

Inventoried clothing and accessories that were out of place back to their proper locations.

Northside Indpendent School District. 5900 Evers Road. San Antonio, Texas 78238.

Substitute Teacher 210-***-****. (09/01/2009-03/13/2013).

Substitute for regular teaching staff during absences.

Adecco/Gallagher & Basset Inc. 12015 San Pedro Ave. # 100 San Antonio, Texas 78216.

210-***-****. (04/05/2011-05/06/2011).

Texas Worker's Comp Claims Assistant:

Research claim information on-line and enter new data into existing claim system as information

is received with goals of accuracy.

Provide a working knowledge in the area of Workers Compensation claims.

Respond to all inquiries from “customers” (defined as: patients, employers, attorneys, insurance

companies, etc.) with goals of timeliness.

Make outgoing calls to customers on new claims as appropriate in order to keep the claims

moving along a path toward ultimate payment.

Handle inbound phone calls from customers.

Review incoming documentation.

Assist with special projects as needed.

Datamark Inc/USAA Bank. 43 Butterfield Circle El Paso, Texas.

Data Entry/Imaging 800-***-****. (04/03/2010-12/05/2010).

Demonstrates and utilizes advanced understanding of USAA bank products and member

landscape.

Routes department calls and e-mail to appropriate staff members.

Prepares correspondence and reports to Bank Managers.

Ensures data to and from EMG member is treated with appropriate level of confidentiality.

Assists in various types of departmental projects, including company-wide initiatives.

Data entry military demographics from a customer opening a checking/savings account.

Provide compliance input on business action plans, projects or operational requests.

• Separate banking documents for the scanning department.

Leading Edge Personnel/Well Med. 3601 NW Loop 410 San Antonio, Texas 78216.

210-***-****. (01/05/2009-07/14/2009).

Referral Coordinator Assistant:

Knowledge of Healthcare Industry and related business functions Advanced course of study in

information technology, business or other field 3+ years of experience in application

implementation and support, or systems design and database programming

Data entry and process referrals/authorizations into the computer.

Supports the UM Specialist by handling all administrative and technical functions

of the authorization process including intake, logging, and tracking the status.

Eye Care Centers of America. 175 E. Houston Street San Antonio, Texas 78205.

210-***-****. (02/05/2007-02/15/2008).

Claims Specialist I:

Reviews and adjudicates Medicaid/ Medicare medical claims in

accordance with CMS claim processing guidelines.

Role requires strong keyboard skills, attention to detail and the ability to work independently in

a production environment.

With moderate direction, handle commercial claims of low to moderate exposure and

complexity.

Resolve claims according to Best Practices and within authority limits.

May handle multi-party claims.

May be dedicated to handle claims for specific accounts.

Ability to interface with insurance companies, clients, and management.

Perform follow up with insurance companies on unpaid insurance accounts and makes

adjustments accordingly.

Maintains strictest confidentiality in regards to client information.

Ability to examine documents for accuracy and completeness.

Effective verbal and written communication skills.

Ability to take initiative and work independently.

Code records by following prescribed coding standards such as ICD 9.

Assign appropriate medical codes to all diagnosis and services.

Follow up with insurance companies to verify claims submission for accuracy.

Kinetic Concepts Inc. P.O. Box 659508 San Antonio, Texas 78265.

Claims Specialist I

1-800-***-****. (02/14/2004-12/05/2005).

Determines covered medical insurance losses by studying provisions of policy or certificate.

Establishes proof of loss by studying medical documentation; assembling additional information

as required from outside sources, including claimant, physician, employer, hospital, and other

insurance companies; initiating or conducting investigation of questionable claims.

Documents medical claims actions by completing forms, reports, logs, and records.

Resolves medical claims by approving or denying documentation; calculating benefit due;

initiating payment or composing denial letter.

Ensures legal compliance by following company policies, procedures, guidelines, as well as state

and federal insurance regulations.

Maintains quality customer services by following customer service practices; responding to

customer inquiries.

Provides legal support by assembling documentation for settlement action.

Protects operations by keeping claims information confidential.

Prepares reports by collecting, analyzing, and summarizing information.

Updates job knowledge by participating in educational opportunities; reading professional

publications; maintaining personal networks; participating in professional organizations.

Accomplishes organization goals by accepting ownership for accomplishing new and different

requests; exploring opportunities to add value to job accomplishments.

Cameron Tucker Consulting. 8700 Crown Hill Blvd. Suite 303 San Antonio, Texas 78209.

210-***-****. (08/30/2003-02/14/2004).

Claims Specialist I

Act as a contact person for the field nurses, medical professionals, ship pending leads and claim

processors to facilitate the organization of paperwork required for the processing of

Medicaid/Medicare claims.

Process claim adjustments, insurance take backs, and write offs, including

Identify and respond to patterns of denials or billing practices and perform complex

account(s) investigation as needed to achieve resolution.

Data entry AOB's and POD's.

Effectively interact with accounting, clinical, and admission staff as well as management.

Contact this candidate